MEDICARE: MR. JEFFREY BRIAN 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	363A00000X	Physician Assistant	102867	NC

General Provider Information

NPI Number	:	1700837127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY BRIAN MARTIN PA

Provider Business Mailing Address
First Line	:	8330 LISMORE ST
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-8854
Country	:	US
Telephone Number	:
Fax Number	:	336-794-0501

Provider Business Practice Location Address
First Line	:	145 KIMEL PARK DR
Second Line	:	SUITE 220
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6984
Country	:	US
Telephone Number	:	336-794-0057
Fax Number	:	336-794-0501

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	02/01/2024

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