Provider Demographics
NPI:1104688506
Name:MARTIN, KAMI (PA-C)
Entity type:Individual
Prefix:
First Name:KAMI
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAMI
Other - Middle Name:
Other - Last Name:TABOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15323 E 215TH ST
Mailing Address - Street 2:
Mailing Address - City:PECULIAR
Mailing Address - State:MO
Mailing Address - Zip Code:64078-9599
Mailing Address - Country:US
Mailing Address - Phone:816-605-3202
Mailing Address - Fax:
Practice Address - Street 1:315 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-1704
Practice Address - Country:US
Practice Address - Phone:417-235-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023049290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant