Provider Demographics
NPI:1598995417
Name:MARTIN, AUTUMN MARIE (MS,FNP)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS,FNP
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:MARIE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS,FNP
Mailing Address - Street 1:900 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:JULESBURG
Mailing Address - State:CO
Mailing Address - Zip Code:80737-1121
Mailing Address - Country:US
Mailing Address - Phone:970-353-9403
Mailing Address - Fax:970-353-9906
Practice Address - Street 1:900 CEDAR ST
Practice Address - Street 2:
Practice Address - City:JULESBURG
Practice Address - State:CO
Practice Address - Zip Code:80737-1121
Practice Address - Country:US
Practice Address - Phone:970-353-9403
Practice Address - Fax:970-353-9906
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP10050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84427060Medicaid