Provider Demographics
NPI:1457346793
Name:MARTIN, PATRICK ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:ALLEN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 TRINITY DR STE 14
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2362
Mailing Address - Country:US
Mailing Address - Phone:505-500-8213
Mailing Address - Fax:866-611-2891
Practice Address - Street 1:2610 TRINITY DR STE 14
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2362
Practice Address - Country:US
Practice Address - Phone:505-500-8213
Practice Address - Fax:866-611-2891
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0503207QH0002X
NMMD20040503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47951567Medicaid
I20173Medicare UPIN