Healthcare Provider Details

I. General information

NPI: 1013262112
Provider Name (Legal Business Name): TANYA R MARTIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12001 Q ST
OMAHA NE
68137-3542
US

IV. Provider business mailing address

12001 Q ST
OMAHA NE
68137-3542
US

V. Phone/Fax

Practice location:
  • Phone: 402-592-0328
  • Fax: 402-592-4170
Mailing address:
  • Phone: 402-592-0328
  • Fax: 402-592-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1932
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1932
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: