Provider Demographics
NPI:1215929690
Name:MARTIN, DAVID E (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2377
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83206-2377
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-7869
Practice Address - Street 1:845 W CENTER ST
Practice Address - Street 2:SUITE 200
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-4205
Practice Address - Country:US
Practice Address - Phone:208-232-6260
Practice Address - Fax:208-232-6259
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA39363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0021913Medicaid
ID000010151329OtherBSI - POKY
IDPANR7OtherBCI - POKY
ID0021913Medicaid
IDPANR7OtherBCI - POKY