Provider Demographics
NPI:1760500243
Name:MARTIN, ROBERTA (RN)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S. MERCER STREET
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-4572
Mailing Address - Country:US
Mailing Address - Phone:724-658-4688
Mailing Address - Fax:724-658-8810
Practice Address - Street 1:1000 S MERCER ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-4672
Practice Address - Country:US
Practice Address - Phone:724-658-4688
Practice Address - Fax:724-658-8810
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN502257L261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016551700001Medicaid