=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174566392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTIN L. LITTLE PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 10/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5637 MARINE PKWY
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-845-9115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9909 SAN SEBASTIAN WAY
-----------------------------------------------------
City | PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34668-3554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-842-3626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9102061
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------