Provider Demographics
NPI:1609949312
Name:MARTIN, ROGER F (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:F
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:18610 NW CORNELL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9223
Practice Address - Country:US
Practice Address - Phone:503-216-9360
Practice Address - Fax:503-216-9363
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ795164Medicaid
OR500604720Medicaid
NM17685028Medicaid
ORR162303Medicare PIN
ORR162301Medicare PIN
ORR162306Medicare PIN
ORR162304Medicare PIN
NM17685028Medicaid
ORR162302Medicare PIN
ORR162305Medicare PIN