Provider Demographics
NPI:1407841000
Name:MARTIN, BRENDA (NPC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:BURKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:586 MOORESTOWN DR
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:PA
Practice Address - Zip Code:18014-9713
Practice Address - Country:US
Practice Address - Phone:610-746-2010
Practice Address - Fax:610-746-2060
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007413363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P71396Medicare UPIN
063880SN4Medicare ID - Type Unspecified