Healthcare Provider Details

I. General information

NPI: 1427338698
Provider Name (Legal Business Name): ANTHONY S. MARTIN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 ACADEMY RD
MONMOUTH ME
04259-7035
US

IV. Provider business mailing address

180 CHURCH HILL RD SUITE 1
LEEDS ME
04263-3418
US

V. Phone/Fax

Practice location:
  • Phone: 207-524-3501
  • Fax: 207-933-9645
Mailing address:
  • Phone: 207-524-3501
  • Fax: 207-524-2093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1399
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: