Basic Information
| Provider Information | |||||||||
| NPI: | 1891748315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 430 | ||||||||
| Address2: | |||||||||
| City: | SPANISH FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846600430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987136 | ||||||||
| FaxNumber: | 6169759827 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 NORTH 1100 EAST | ||||||||
| Address2: | |||||||||
| City: | AMERICAN FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017146570 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | EMTL-2020-001 | GU | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MTL-2018-027 | GU | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M-2221 | GU | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 341513 | UT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 491910 | 01 | UT | DESERET MUTUAL | OTHER | 97341513101001 | 01 | UT | BCBS | OTHER | 107008020102 | 01 | UT | SELECT HEALTH | OTHER | D2015 | 05 | UT | MEDICAID | 870636000MA1 | 01 | UT | EDUCATORS MUTUAL | OTHER |