Provider Demographics
NPI:1184733743
Name:MARTIN, JOLENA M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JOLENA
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JOLENA
Other - Middle Name:M
Other - Last Name:KING, SOSAMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12450 COUNTY ROAD 420
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-2202
Mailing Address - Country:US
Mailing Address - Phone:217-474-5658
Mailing Address - Fax:
Practice Address - Street 1:3203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-7727
Practice Address - Country:US
Practice Address - Phone:903-266-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002607363A00000X
TXPA15326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00382765OtherRAILROAD MEDICARE
385364383OtherTRICARE PROVIDER NUMBER
Q58991Medicare UPIN
IL0407950001Medicare NSC
ILK37438Medicare PIN