Basic Information
| Provider Information | |||||||||
| NPI: | 1174880447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | RICKY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775383 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127653153 | ||||||||
| FaxNumber: | 8123753477 | ||||||||
| Practice Location | |||||||||
| Address1: | 2326 18TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728680 | ||||||||
| FaxNumber: | 8123735497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2012 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10002016A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 10002016A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.