MEDICARE: RODNEYSHA MARTIN PA

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	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1164125795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODNEYSHA MARTIN PA

Provider Business Mailing Address
First Line	:	1220 N WASHINGTON ST
Second Line	:
City	:	FORREST CITY
State	:	AR
Zip	:	72335-2121
Country	:	US
Telephone Number	:	870-594-6001
Fax Number	:	501-823-3623

Provider Business Practice Location Address
First Line	:	1220 N WASHINGTON ST
Second Line	:
City	:	FORREST CITY
State	:	AR
Zip	:	72335-2121
Country	:	US
Telephone Number	:	870-594-6001
Fax Number	:	501-823-3623

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

Provider Enumeration Date	:	03/23/2023
Last Update Date	:	03/23/2023

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