Provider Demographics
NPI:1205611431
Name:MARTIN, COLLETTE (PA-C)
Entity type:Individual
Prefix:
First Name:COLLETTE
Middle Name:
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 1:125 LASALLE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2311
Mailing Address - Country:US
Mailing Address - Phone:860-906-1289
Mailing Address - Fax:860-906-1269
Practice Address - Street 1:125 LASALLE RD STE 208
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2311
Practice Address - Country:US
Practice Address - Phone:860-906-1289
Practice Address - Fax:860-906-1269
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2024-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT6253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant