Provider Demographics
NPI:1194814632
Name:MARTIN, JEFFREY S (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:MARTIN
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 1:608 DAWSON ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-5712
Mailing Address - Country:US
Mailing Address - Phone:910-667-0041
Mailing Address - Fax:910-667-0019
Practice Address - Street 1:608 DAWSON ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-5712
Practice Address - Country:US
Practice Address - Phone:910-667-0041
Practice Address - Fax:910-667-0019
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102353363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS62990Medicare UPIN