Provider Demographics
NPI:1578043865
Name:MARTIN, AUTUMN L (PA)
Entity Type:Individual
Prefix:MISS
First Name:AUTUMN
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 E STAR LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5516
Mailing Address - Country:US
Mailing Address - Phone:208-484-3740
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA-1632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant