MEDICARE: HALEY MARTIN

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	207Q00000X	Family Medicine Physician	AP140445	TX
2	363LF0000X	Family Nurse Practitioner	AP140445	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568929552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY MARTIN

Provider Business Mailing Address
First Line	:	1048 ALEDO RIDGE CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76108-3098
Country	:	US
Telephone Number	:	817-694-5232
Fax Number	:	817-441-9282

Provider Business Practice Location Address
First Line	:	1048 ALEDO RIDGE CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76108-3098
Country	:	US
Telephone Number	:	817-694-5232
Fax Number	:	817-441-9282

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

Provider Enumeration Date	:	02/26/2019
Last Update Date	:	10/12/2023

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Directions to “ HALEY MARTIN ” Practice Location

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