Provider Demographics
NPI:1013237866
Name:SALCIDO, MARTHA C (PA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:C
Last Name:SALCIDO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:C
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:150 TEJAS PL
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3211
Mailing Address - Fax:805-929-6440
Practice Address - Street 1:425 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2805
Practice Address - Country:US
Practice Address - Phone:805-737-1774
Practice Address - Fax:805-737-1772
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 20298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM71074FMedicaid
CAW1508BMedicare Oscar/Certification