1285097774 NPI number — MRS. ADRIENNE NICOLE MARTIN PA-C

Table of content: MRS. ADRIENNE NICOLE MARTIN PA-C (NPI 1285097774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285097774 NPI number — MRS. ADRIENNE NICOLE MARTIN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
ADRIENNE
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1285097774
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CREWS AVE
Provider Second Line Business Mailing Address:
APT. G-21
Provider Business Mailing Address City Name:
ALAMOGORDO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88310-4406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-491-9658
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 E 10TH STREET,
Provider Second Line Business Practice Location Address:
PMS-ALAMOGORDO FAMILY HEALTH CENTER
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-434-2960
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2016

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:  PA2016-0010 , 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)





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