Provider Demographics
NPI:1700837127
Name:MARTIN, JEFFREY BRIAN (PA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:BRIAN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8330 LISMORE ST
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:336-794-0501
Practice Address - Street 1:145 KIMEL PARK DR
Practice Address - Street 2:SUITE 220
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6984
Practice Address - Country:US
Practice Address - Phone:336-794-0057
Practice Address - Fax:336-794-0501
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP18026Medicare UPIN
NC2753012Medicare ID - Type Unspecified