Basic Information
| Provider Information | |||||||||
| NPI: | 1013262112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4920 S 30TH ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681071590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027344110 | ||||||||
| FaxNumber: | 4027343990 | ||||||||
| Practice Location | |||||||||
| Address1: | 4920 S 30TH ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681071590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027344110 | ||||||||
| FaxNumber: | 4027343990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2012 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1932 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.