Basic Information
| Provider Information | |||||||||
| NPI: | 1295281541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINSON | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1441 NE 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | PAYETTE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836615420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086429376 | ||||||||
| FaxNumber: | 2086429598 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 E 12TH ST | ||||||||
| Address2: | |||||||||
| City: | EMMETT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836173626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083651065 | ||||||||
| FaxNumber: | 2083651068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | APPLIED FOR | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-1401 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.