Healthcare Provider Details

I. General information

NPI: 1508860420
Provider Name (Legal Business Name): JEANNE R. MARTIN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 RICHLAND AVE W
AIKEN SC
29801-3828
US

IV. Provider business mailing address

PO BOX 1132
AIKEN SC
29802-1132
US

V. Phone/Fax

Practice location:
  • Phone: 803-648-3130
  • Fax: 803-648-9860
Mailing address:
  • Phone: 803-648-3130
  • Fax: 803-648-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number423
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: