Provider Demographics
NPI:1396355608
Name:MARTIN, KATHRYN VIKTORIA (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:VIKTORIA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
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 704
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-0704
Mailing Address - Country:US
Mailing Address - Phone:781-534-5711
Mailing Address - Fax:
Practice Address - Street 1:1265 WELCH RD STE 100
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-5102
Practice Address - Country:US
Practice Address - Phone:650-725-6959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant