Basic Information
| Provider Information | |||||||||
| NPI: | 1649883570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ST MARTIN | ||||||||
| FirstName: | CHANEL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1907 HIGHWAY 44 W | ||||||||
| Address2: | |||||||||
| City: | INVERNESS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344533801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523442273 | ||||||||
| FaxNumber: | 3523442204 | ||||||||
| Practice Location | |||||||||
| Address1: | 1907 HIGHWAY 44 W | ||||||||
| Address2: | |||||||||
| City: | INVERNESS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344533801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523442273 | ||||||||
| FaxNumber: | 3523442204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2020 | ||||||||
| LastUpdateDate: | 08/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 000758-P.A. | PR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.