Provider Demographics
NPI:1518022961
Name:DEFORE, MARTHA ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANNE
Last Name:DEFORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:ANNE
Other - Last Name:MASELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8142 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-2422
Mailing Address - Country:US
Mailing Address - Phone:520-237-9299
Mailing Address - Fax:
Practice Address - Street 1:1601 W SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2682
Practice Address - Country:US
Practice Address - Phone:520-872-4901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18506363A00000X
AZ3790207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18506OtherSTATE LICENCE