1598995417 NPI number — AUTUMN MARIE MARTIN MS,FNP

Table of content: AUTUMN MARIE MARTIN MS,FNP (NPI 1598995417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598995417 NPI number — AUTUMN MARIE MARTIN MS,FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
AUTUMN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS,FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLER
Provider Other First Name:
AUTUMN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS,FNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1598995417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JULESBURG
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80737-1121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-353-9403
Provider Business Mailing Address Fax Number:
970-353-9906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JULESBURG
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80737-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-353-9403
Provider Business Practice Location Address Fax Number:
970-353-9906
Provider Enumeration Date:
07/27/2009

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: 363LF0000X , with the licence number:  NP10050 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 84427060 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".