Healthcare Provider Details

I. General information

NPI: 1609358944
Provider Name (Legal Business Name): KERRY ANN MARTIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 ANNAPOLIS RD
ODENTON MD
21113-1602
US

IV. Provider business mailing address

7809 WISCONSIN AVE
BETHESDA MD
20814-3523
US

V. Phone/Fax

Practice location:
  • Phone: 443-351-3917
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006936
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: