MEDICARE: STEPHEN DOUGLAS MARTIN AGC, MPAS, PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA 9101220	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9101220	OTHER	FL	PA LICENSE NUMBER
2	U6812Z	OTHER	FL	SUPPLIER ID

General Provider Information

NPI Number	:	1619916202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN DOUGLAS MARTIN AGC, MPAS, PA-C

Provider Business Mailing Address
First Line	:	1401 N HIMES AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607
Country	:	US
Telephone Number	:	813-393-3725
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 N HIMES AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607
Country	:	US
Telephone Number	:	813-393-3725
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	07/01/2010

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