Healthcare Provider Details

I. General information

NPI: 1093242190
Provider Name (Legal Business Name): COURTNEY MARIE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DOCTOR CALVIN JONES HWY STE A-1
WAKE FOREST NC
27587
US

IV. Provider business mailing address

1 EMBARCADERO CTR STE 1900
SAN FRANCISCO CA
94111-3723
US

V. Phone/Fax

Practice location:
  • Phone: 888-663-6331
  • Fax: 415-252-7176
Mailing address:
  • Phone: 888-663-6331
  • Fax: 415-252-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13322
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: