Provider Demographics
NPI:1942571294
Name:MARTIN, BRIAN C (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
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:PO BOX 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:DAVOL 141
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-854-2504
Practice Address - Fax:401-854-2519
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant