Provider Demographics
NPI:1417081316
Name:MARTIN, BRENT CURTIS
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:CURTIS
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:C
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:10 MEDICAL CENTER BLVD STE C
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3163
Practice Address - Country:US
Practice Address - Phone:936-639-4393
Practice Address - Fax:877-916-5022
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05182363A00000X
COPA.0003074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00888242OtherRAILROAD MEDICARE
CO37455079Medicaid
CO37455079Medicaid