MEDICARE: BREANNE MARIE MARTIN

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1649058058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNE MARIE MARTIN

Provider Business Mailing Address
First Line	:	2266 WESTGLEN PARK DR
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-4014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2266 WESTGLEN PARK DR
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-4014
Country	:	US
Telephone Number	:	636-487-7589
Fax Number	:

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

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	09/18/2023

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Directions to “ BREANNE MARIE MARTIN ” Practice Location

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