Provider Demographics
NPI:1700944501
Name:MARTIN, REGINA MARIE (PA C)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
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 1:4231 NORTHWOODS TRAIL
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074
Mailing Address - Country:US
Mailing Address - Phone:410-374-9391
Mailing Address - Fax:410-374-1866
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-521-2200
Practice Address - Fax:410-496-7541
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKL09Medicare PIN
MD136286Y9FMedicare PIN