Provider Demographics
NPI:1184648230
Name:MARTIN, KIRK (PAC)
Entity Type:Individual
Prefix:MR
First Name:KIRK
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PAC
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 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4943
Practice Address - Street 1:13670 WALSINGHAM RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3532
Practice Address - Country:US
Practice Address - Phone:727-593-9848
Practice Address - Fax:727-596-4532
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017543900Medicaid
R96125Medicare UPIN
FLU1223WMedicare PIN
FL017543900Medicaid