Provider Demographics
NPI:1093740078
Name:TAYLOR, MARTIN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:LEE
Last Name:TAYLOR
Suffix:
Gender:M
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 1:914 PINEHURST ROAD SE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2219
Mailing Address - Country:US
Mailing Address - Phone:505-896-9412
Mailing Address - Fax:505-896-2505
Practice Address - Street 1:914 PINEHURST ROAD SE
Practice Address - Street 2:SUITE 102
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-2219
Practice Address - Country:US
Practice Address - Phone:505-896-9412
Practice Address - Fax:505-896-2505
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2003-002363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10752871Medicaid
Q02856Medicare UPIN
NM10752871Medicaid
343402201Medicare PIN