Healthcare Provider Details

I. General information

NPI: 1851222087
Provider Name (Legal Business Name): COLBY MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 SAN PEDRO DR
CHESAPEAKE VA
23322-8059
US

IV. Provider business mailing address

613 SAN PEDRO DR
CHESAPEAKE VA
23322-8059
US

V. Phone/Fax

Practice location:
  • Phone: 757-687-9562
  • Fax:
Mailing address:
  • Phone: 757-687-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110012000
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: