Provider Demographics
NPI:1942329636
Name:MARTIN, VINCE RUSSELL (PA)
Entity Type:Individual
Prefix:
First Name:VINCE
Middle Name:RUSSELL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4216
Mailing Address - Country:US
Mailing Address - Phone:918-775-0007
Mailing Address - Fax:918-775-8910
Practice Address - Street 1:700 W CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-4216
Practice Address - Country:US
Practice Address - Phone:918-775-0007
Practice Address - Fax:918-775-8910
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1514363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1514OtherOKLAHOMA LICENSE
OK34366OtherOK BUR OF NARCOTICS & DD
OK34366OtherOK BUR OF NARCOTICS & DD