Provider Demographics
NPI:1164615985
Name:MARTIN, MICHELLE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:08242007789470
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1805 SHEA CENTER DR STE 301
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2277
Mailing Address - Country:US
Mailing Address - Phone:303-225-0025
Mailing Address - Fax:303-225-0029
Practice Address - Street 1:10103 RIDGEGATE PKWY STE G23
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5524
Practice Address - Country:US
Practice Address - Phone:303-225-0025
Practice Address - Fax:303-225-0029
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24677078Medicaid
CO24677078Medicaid