MEDICARE: MARIE DEBORAH MARTIN PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	200450024NP PMHNP-PP	OR

General Provider Information

NPI Number	:	1033254909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE DEBORAH MARTIN PMHNP

Provider Business Mailing Address
First Line	:	1012 SW KING AVE STE 305
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-1110
Country	:	US
Telephone Number	:	503-241-2523
Fax Number	:	503-715-0422

Provider Business Practice Location Address
First Line	:	1012 SW KING AVE STE 305
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-1110
Country	:	US
Telephone Number	:	503-241-2523
Fax Number	:	503-715-0422

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	09/20/2011

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