Provider Demographics
NPI:1639180409
Name:MARTIN, JEFFREY EDWARD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:EDWARD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 475
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-9766
Mailing Address - Country:US
Mailing Address - Phone:580-245-1182
Mailing Address - Fax:580-208-3199
Practice Address - Street 1:611 ZEAGLER DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3810
Practice Address - Country:US
Practice Address - Phone:386-328-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0084629367500000X
FLAPRN9223834367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y758OtherBC/BS AR
OK200075140AMedicaid