Provider Demographics
NPI:1730476383
Name:ROTHERMEL, MARTYN GREGORY
Entity Type:Individual
Prefix:MR
First Name:MARTYN
Middle Name:GREGORY
Last Name:ROTHERMEL
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MARTYN
Other - Middle Name:GREGORY
Other - Last Name:ROTHERMEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-542-7972
Mailing Address - Fax:904-542-7394
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-542-7972
Practice Address - Fax:904-542-7394
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN38626363LF0000X
FLARNP9381113363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily