Healthcare Provider Details

I. General information

NPI: 1770733255
Provider Name (Legal Business Name): DANIEL MARTINO PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 N 12TH AVE
CORNELIUS OR
97113-9029
US

IV. Provider business mailing address

85 N 12TH AVE
CORNELIUS OR
97113-9029
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-8562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA150160
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberPA150160
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: