Provider Demographics
NPI:1780800979
Name:DJAN, MARTIN EBO (PA-C)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:EBO
Last Name:DJAN
Suffix:
Gender:M
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:ONE CENTURIAN DR
Mailing Address - Street 2:SUITE 310A
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-918-6300
Mailing Address - Fax:302-918-6330
Practice Address - Street 1:ONE CENTURIAN DR
Practice Address - Street 2:SUITE 310A
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-918-6300
Practice Address - Fax:302-918-6330
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant