Basic Information
| Provider Information | |||||||||
| NPI: | 1427157148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356289393 | ||||||||
| FaxNumber: | 4356289382 | ||||||||
| Practice Location | |||||||||
| Address1: | 1490 E FOREMASTER DR | ||||||||
| Address2: | STE 150 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847904488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356289393 | ||||||||
| FaxNumber: | 4356289382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 03/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 288527-1206 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 363A00000X | 288527-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.