Provider Demographics
NPI:1912078585
Name:MARTIN, GRETCHEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:L
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1015 S MOUNT CARMEL PL
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6604
Mailing Address - Country:US
Mailing Address - Phone:620-232-5581
Mailing Address - Fax:
Practice Address - Street 1:1015 S MOUNT CARMEL PL
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6604
Practice Address - Country:US
Practice Address - Phone:620-232-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0000427029OtherBCBS