Healthcare Provider Details

I. General information

NPI: 1841629417
Provider Name (Legal Business Name): JASON M MARTIN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 W 23RD ST STE C
PANAMA CITY FL
32405-2370
US

IV. Provider business mailing address

4040 ARBOR TRACE DR UNIT T
LYNN HAVEN FL
32444-6742
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax: 877-413-5104
Mailing address:
  • Phone: 334-797-6165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-103235
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9380731
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: