Basic Information
| Provider Information | |||||||||
| NPI: | 1902242399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | BRYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083672121 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083672121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2013 | ||||||||
| LastUpdateDate: | 05/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 05/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | DO188047 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | Q5864 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | O-1146 | ID | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.