Provider Demographics
NPI:1134469265
Name:MARTIN, EVAN KELLER (PA-C)
Entity type:Individual
Prefix:MRS
First Name:EVAN
Middle Name:KELLER
Last Name:MARTIN
Suffix:
Gender:F
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 1:1037 CONNEAUT AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-5301
Mailing Address - Country:US
Mailing Address - Phone:419-373-6046
Mailing Address - Fax:419-352-9048
Practice Address - Street 1:1037 CONNEAUT AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-5301
Practice Address - Country:US
Practice Address - Phone:419-373-6046
Practice Address - Fax:419-352-9048
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.001611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant