Healthcare Provider Details

I. General information

NPI: 1225764855
Provider Name (Legal Business Name): JACOB MARTIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4466 W BRISTOL RD
FLINT MI
48507-3170
US

IV. Provider business mailing address

4466 W BRISTOL RD
FLINT MI
48507-3170
US

V. Phone/Fax

Practice location:
  • Phone: 810-733-1200
  • Fax: 810-733-0688
Mailing address:
  • Phone: 810-733-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: