Provider Demographics
NPI:1245522895
Name:MARTIN, JEREMY G (CRNA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:G
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 55990
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-5990
Mailing Address - Country:US
Mailing Address - Phone:501-227-0700
Mailing Address - Fax:501-227-0744
Practice Address - Street 1:3024 STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7415
Practice Address - Country:US
Practice Address - Phone:501-227-0700
Practice Address - Fax:501-227-0744
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARR82456367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered