Provider Demographics
NPI:1952652141
Name:MARTIN, THOMAS MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N GILBERT RD STE 104
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4511
Mailing Address - Country:US
Mailing Address - Phone:480-834-3507
Mailing Address - Fax:480-834-3982
Practice Address - Street 1:625 N GILBERT RD STE 104
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-4511
Practice Address - Country:US
Practice Address - Phone:480-834-3507
Practice Address - Fax:480-834-3982
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5245363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ740722Medicaid