Provider Demographics
NPI:1225398563
Name:MARTIN, DALE L (CRNA)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7178 BLUE JACK DR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-7304
Mailing Address - Country:US
Mailing Address - Phone:601-447-1705
Mailing Address - Fax:
Practice Address - Street 1:1040 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7809
Practice Address - Country:US
Practice Address - Phone:850-916-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR787462367500000X
FLAPRN11009121367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I438792OtherMEDICARE PTAN
MS3481631OtherUNITED HEALTHCARE
MS4017520OtherCIGNA
MS03280005Medicaid
MS9060979OtherAETNA
MSP01109800OtherRAILROAD MEDICARE