Provider Demographics
NPI:1619916202
Name:MARTIN, STEPHEN DOUGLAS (AGC, MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DOUGLAS
Last Name:MARTIN
Suffix:
Gender:M
Credentials:AGC, MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N HIMES AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607
Mailing Address - Country:US
Mailing Address - Phone:813-393-3725
Mailing Address - Fax:
Practice Address - Street 1:1401 N HIMES AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:813-393-3725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9101220363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9101220OtherPA LICENSE NUMBER
FLU6812ZOtherSUPPLIER ID
FLU6812ZOtherSUPPLIER ID