Provider Demographics
NPI:1356651426
Name:MARTIN, RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:105 SHORT ST
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-3221
Mailing Address - Country:US
Mailing Address - Phone:202-236-1072
Mailing Address - Fax:
Practice Address - Street 1:9420 KEY WEST AVE STE 420
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6509
Practice Address - Country:US
Practice Address - Phone:301-258-1919
Practice Address - Fax:301-258-9180
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004286363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical