Healthcare Provider Details

I. General information

NPI: 1417633306
Provider Name (Legal Business Name): HEIDIMAE REGINA MARTIN PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 09 5040 1 UNM
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

MSC 09 5040 1 UNM
ALBUQUERQUE NM
87131
US

V. Phone/Fax

Practice location:
  • Phone: 505-620-6567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2024-0138
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: