Provider Demographics
NPI:1285097774
Name:MARTIN, ADRIENNE NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ADRIENNE
Middle Name:NICOLE
Last Name:MARTIN
Suffix:
Gender:F
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 1:100 CREWS AVE
Mailing Address - Street 2:APT. G-21
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-4406
Mailing Address - Country:US
Mailing Address - Phone:765-491-9658
Mailing Address - Fax:
Practice Address - Street 1:1501 E 10TH STREET,
Practice Address - Street 2:PMS-ALAMOGORDO FAMILY HEALTH CENTER
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310
Practice Address - Country:US
Practice Address - Phone:575-434-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2016-0010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant