Provider Demographics
NPI:1013228394
Name:MARTIN, CLINTON RICHARD (PA)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:RICHARD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:9101 W SAHARA AVE # 105-51
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5772
Mailing Address - Country:US
Mailing Address - Phone:702-254-1425
Mailing Address - Fax:702-243-5012
Practice Address - Street 1:3650 S POINTE CIR STE 106
Practice Address - Street 2:
Practice Address - City:LAUGHLIN
Practice Address - State:NV
Practice Address - Zip Code:89029-0422
Practice Address - Country:US
Practice Address - Phone:702-254-1425
Practice Address - Fax:702-243-5012
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5486363A00000X
NVPA1351363A00000X
NVPA0270363A00000X
TXPA12064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1013228394Medicaid
NV1366544124Medicaid