Provider Demographics
NPI:1629001565
Name:MARTIN, NICHOLE (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
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 1:614 EASTERN SHORE DR STE C
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5940
Mailing Address - Country:US
Mailing Address - Phone:443-260-2660
Mailing Address - Fax:443-260-2754
Practice Address - Street 1:100 EAST CARROLL STREET
Practice Address - Street 2:STE 400
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801
Practice Address - Country:US
Practice Address - Phone:410-543-7065
Practice Address - Fax:410-543-7062
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKP81Medicare PIN
P08412Medicare UPIN