Provider Demographics
NPI:1952398232
Name:GRIFFIN MARTIN, THERESA ANN (PAC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
Last Name:GRIFFIN MARTIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:MITRIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:238 S MERIDIAN RD STE B
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-2925
Mailing Address - Country:US
Mailing Address - Phone:330-754-3217
Mailing Address - Fax:330-841-4644
Practice Address - Street 1:238 S MERIDIAN RD STE B
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-2925
Practice Address - Country:US
Practice Address - Phone:330-754-3217
Practice Address - Fax:330-752-9284
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.000540RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0073657Medicaid
OH0073657Medicaid
S46835Medicare UPIN