Provider Demographics
NPI:1346753522
Name:MARTIN, MICHAEL (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6185 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64152
Mailing Address - Country:US
Mailing Address - Phone:816-569-1506
Mailing Address - Fax:816-569-1505
Practice Address - Street 1:324 N QUEEN ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-4932
Practice Address - Country:US
Practice Address - Phone:252-522-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021002927363LF0000X
NC5010050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty