Provider Demographics
NPI:1336184043
Name:PAO, MARTHA C (PA C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:C
Last Name:PAO
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 1:5870 HIATUS RD
Mailing Address - Street 2:REGIONAL ADMIN OFFICE
Mailing Address - City:TAMRAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-6424
Mailing Address - Country:US
Mailing Address - Phone:954-377-3074
Mailing Address - Fax:865-560-7110
Practice Address - Street 1:1919 112TH ST SW
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3784
Practice Address - Country:US
Practice Address - Phone:425-513-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0175422OtherLIWA
WA8364077Medicaid
WA2414PAOtherBSWA
WA4147PAOtherBSWA
WA2414PAOtherBSWA
WAG8850863Medicare PIN
WAG8863205Medicare PIN
WAGAB39911Medicare PIN
WAP60893Medicare UPIN