Provider Demographics
NPI:1750808069
Name:MARTIN, HEATHER A
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 E RACE AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4653
Mailing Address - Country:US
Mailing Address - Phone:501-279-1512
Mailing Address - Fax:501-203-4001
Practice Address - Street 1:904 E RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4653
Practice Address - Country:US
Practice Address - Phone:501-279-1512
Practice Address - Fax:501-203-4001
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005279363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR221778758Medicaid