Provider Demographics
NPI:1114350246
Name:MARTIN, PAMELA C (COTA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COTA
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 2000
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-2000
Mailing Address - Country:US
Mailing Address - Phone:505-832-4471
Mailing Address - Fax:505-832-4472
Practice Address - Street 1:200 CENTER STREET
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035-2000
Practice Address - Country:US
Practice Address - Phone:505-832-4471
Practice Address - Fax:505-832-4472
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3115224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139Medicaid