1184733743 NPI number — MRS. JOLENA M MARTIN P.A.-C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184733743 NPI number — MRS. JOLENA M MARTIN P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
JOLENA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KING, SOSAMON
Provider Other First Name:
JOLENA
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.A.-C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184733743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12450 COUNTY ROAD 420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75704-2202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-474-5658
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3203 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDALE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75771-7727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-266-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  085002607 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA15326 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00382765 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 385364383 . This is a "TRICARE PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".




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