Healthcare Provider Details

I. General information

NPI: 1386009165
Provider Name (Legal Business Name): MARTIN OKOTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

1653 RED BARN DR
CORDOVA TN
38016-6089
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: