Basic Information
Provider Information | |||||||||
NPI: | 1568482297 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 N SAN ANTONIO RD | ||||||||
Address2: |   | ||||||||
City: | SANTA BARBARA | ||||||||
State: | CA | ||||||||
PostalCode: | 931101316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056815461 | ||||||||
FaxNumber: | 8056815200 | ||||||||
Practice Location | |||||||||
Address1: | 2115 CENTERPOINTE PKWY | ||||||||
Address2: |   | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 934551334 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8053467230 | ||||||||
FaxNumber: | 8053467272 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA13976 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 00A139760 | 05 | CA |   | MEDICAID | PA13976 | 01 | CA | MED LICENSE | OTHER |