Provider Demographics
NPI:1992093579
Name:GANTT, MARTI M (PA-C)
Entity type:Individual
Prefix:
First Name:MARTI
Middle Name:M
Last Name:GANTT
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75151-0368
Mailing Address - Country:US
Mailing Address - Phone:903-875-2188
Mailing Address - Fax:903-875-2186
Practice Address - Street 1:3200 W HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2449
Practice Address - Country:US
Practice Address - Phone:903-875-2188
Practice Address - Fax:903-875-2186
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07344363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX301870YTZEMedicare PIN