Healthcare Provider Details

I. General information

NPI: 1902812324
Provider Name (Legal Business Name): TINA MARTIN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET
JACKSON MS
39216
US

IV. Provider business mailing address

PO BOX 4528
JACKSON MS
39296-4528
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5500
  • Fax: 601-984-5499
Mailing address:
  • Phone: 601-984-5500
  • Fax: 601-984-5499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number325064-22
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: