Basic Information
| Provider Information | |||||||||
| NPI: | 1750421632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | REBEKAH | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2841 LORAN DR E | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322165519 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2605 W SWANN AVE | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138767073 | ||||||||
| FaxNumber: | 8138771277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9103989 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.