Provider Demographics
NPI:1417994815
Name:MARTINEAU, MITCHELL DREW (NP)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DREW
Last Name:MARTINEAU
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:ADMINISTRATION
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8100
Mailing Address - Fax:850-863-8548
Practice Address - Street 1:1032 MAR WALT DRIVE
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6661
Practice Address - Country:US
Practice Address - Phone:850-863-8260
Practice Address - Fax:850-862-6098
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11003748363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100848260AMedicaid
OK100848260AMedicaid