Provider Demographics
NPI:1821525916
Name:MARTIN, CONCETTA WHITLEY (PA)
Entity Type:Individual
Prefix:
First Name:CONCETTA
Middle Name:WHITLEY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 STATE HIGHWAY 22 W
Mailing Address - Street 2:
Mailing Address - City:DARDANELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72834-2909
Mailing Address - Country:US
Mailing Address - Phone:479-229-8000
Mailing Address - Fax:479-477-3925
Practice Address - Street 1:1652 STATE HIGHWAY 22 W
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-2909
Practice Address - Country:US
Practice Address - Phone:479-229-8000
Practice Address - Fax:479-477-3925
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2017-031363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPT2017-031OtherARKANSAS STATE MEDICAL BOARD