Healthcare Provider Details

I. General information

NPI: 1053104398
Provider Name (Legal Business Name): TESSICA GRACE MARTIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 BLUEFIELD RD STE A
MOORESVILLE NC
28117-9626
US

IV. Provider business mailing address

2709 WALKERS BRANCH RD
HAMPTONVILLE NC
27020-7857
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-6500
  • Fax:
Mailing address:
  • Phone: 336-469-5438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: