Provider Demographics
NPI:1629080643
Name:MARTIN, JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
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 158
Mailing Address - Street 2:538 N. PASEO DE ONATE
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:HWY 68 #2243 RINCONADA
Practice Address - Street 2:
Practice Address - City:EMBUDO
Practice Address - State:NM
Practice Address - Zip Code:87531
Practice Address - Country:US
Practice Address - Phone:505-579-4255
Practice Address - Fax:505-579-4669
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2011-0005363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant