Provider Demographics
NPI:1942215538
Name:MARTIN, PATRICIA G (PA)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:G
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:PATRICIA
Other - Middle Name:G
Other - Last Name:CLISHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:22 S GREENE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1544
Mailing Address - Country:US
Mailing Address - Phone:410-328-7490
Mailing Address - Fax:410-328-1965
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-7490
Practice Address - Fax:410-328-1965
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00033963Medicaid
MD611353OtherNCPPO
MD240452OtherKAISER
MDK619OtherCAREFIRST REGIONAL
MDP90517Medicare UPIN
MDK619OtherCAREFIRST REGIONAL