Provider Demographics
NPI:1003859174
Name:MARTIN, MICHELLE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PAC
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 330
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-0330
Mailing Address - Country:US
Mailing Address - Phone:606-365-1547
Mailing Address - Fax:606-365-8380
Practice Address - Street 1:100 JAY STREET
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-7511
Practice Address - Country:US
Practice Address - Phone:606-365-1547
Practice Address - Fax:606-365-8380
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA686363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9500353900Medicaid
0969604Medicare ID - Type Unspecified
P44044Medicare UPIN