Provider Demographics
NPI:1053395608
Name:ANDERSON, MARTHA (CNS)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3599 PEAKWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-3108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2118 ROSALIND AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1718
Practice Address - Country:US
Practice Address - Phone:540-981-7653
Practice Address - Fax:540-981-7469
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015-000472364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010066492Medicaid
VA8929335Medicaid
VA000845C19Medicare PIN
VAP26331Medicare UPIN