Provider Demographics
NPI:1245450402
Name:MARTIN, DEBORAH KENNEDY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:KENNEDY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:414 W LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-2954
Mailing Address - Country:US
Mailing Address - Phone:336-789-9492
Mailing Address - Fax:336-789-9587
Practice Address - Street 1:414 W LEBANON ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2954
Practice Address - Country:US
Practice Address - Phone:336-789-9492
Practice Address - Fax:336-789-9587
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
C10361OtherGROUP ORGANIZATION PTAN
VA1245450402Medicaid
DN2980OtherGROUP PTAN
261083931OtherTAX ID