Healthcare Provider Details

I. General information

NPI: 1477198893
Provider Name (Legal Business Name): BRYAN MARTIN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 PIONEER RD
JUPITER FL
33458-9011
US

IV. Provider business mailing address

PO BOX 22239
NEW YORK NY
10087-0001
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112900
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: