Provider Demographics
NPI:1366039232
Name:MARTIN, TABITHA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TABITHA
Other - Middle Name:LYNN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TABITHA MARTIN PA-C
Mailing Address - Street 1:124 DEER PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLAY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:40312-9672
Mailing Address - Country:US
Mailing Address - Phone:606-481-2504
Mailing Address - Fax:
Practice Address - Street 1:318 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3487
Practice Address - Country:US
Practice Address - Phone:859-353-4180
Practice Address - Fax:859-878-1616
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2696363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant