Provider Demographics
NPI:1164441143
Name:MARTIN, KATHLEEN A (NP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 3209
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-884-3980
Practice Address - Fax:208-884-3979
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP88A363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID781786OtherDESERET
ID500029223OtherRAILROAD MEDICARE
ID820367722C012OtherTRICARE
IDNPNB1OtherBLUE CROSS OF IDAHO
ID820367722A010OtherTRICARE
ID000010016728OtherREGENCE BLUE SHIELD OF ID
ID000010016729OtherREGENCE BLUE SHIELD OF ID
ID805800900Medicaid
IDP23257Medicare UPIN
ID820367722A010OtherTRICARE
ID1343147Medicare ID - Type Unspecified