Provider Demographics
NPI:1962566224
Name:MARTIN, JOHN MICHAEL (NP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:NP
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 5386
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-5386
Mailing Address - Country:US
Mailing Address - Phone:228-826-4600
Mailing Address - Fax:
Practice Address - Street 1:1330 R S KIMBALL
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565
Practice Address - Country:US
Practice Address - Phone:228-826-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851501363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126136Medicaid
MS00126136Medicaid