1902831985 NPI number — BROOKE G MARTIN PA

Table of content: BROOKE G MARTIN PA (NPI 1902831985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902831985 NPI number — BROOKE G MARTIN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
BROOKE
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902831985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26028
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-6028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-262-7963
Provider Business Mailing Address Fax Number:
505-232-1627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5150 JOURNAL CENTER BLVD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87109-5900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-262-3233
Provider Business Practice Location Address Fax Number:
505-262-3191
Provider Enumeration Date:
07/11/2006

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: 363AM0700X , with the licence number:  78-PA005 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 59758 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".