Provider Demographics
NPI:1710408430
Name:REA, MARTHA ALICIA
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:ALICIA
Last Name:REA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 E 12TH ST STE 113
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2943
Mailing Address - Country:US
Mailing Address - Phone:562-587-9688
Mailing Address - Fax:
Practice Address - Street 1:3301 E. 12TH ST
Practice Address - Street 2:SUITE 113
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601
Practice Address - Country:US
Practice Address - Phone:562-587-9688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant