Provider Demographics
NPI:1891748315
Name:MARTIN, STACY ANN (MD)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-0430
Mailing Address - Country:US
Mailing Address - Phone:866-898-7136
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:170 NORTH 1100 EAST
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003
Practice Address - Country:US
Practice Address - Phone:801-714-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUEMTL-2020-001207P00000X
GUMTL-2018-027207P00000X
GUM-2221207P00000X
UT341513207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT491910OtherDESERET MUTUAL
UT97341513101001OtherBCBS
UT107008020102OtherSELECT HEALTH
UTD2015Medicaid
UT870636000MA1OtherEDUCATORS MUTUAL
UT97341513101001OtherBCBS
UTD2015Medicaid
UT491910OtherDESERET MUTUAL