Basic Information
| Provider Information | |||||||||
| NPI: | 1932263043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POORE | ||||||||
| FirstName: | MARTA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 TONGASS AVE | ||||||||
| Address2: | |||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072287688 | ||||||||
| FaxNumber: | 9072288468 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 TONGASS AVE | ||||||||
| Address2: | |||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072287688 | ||||||||
| FaxNumber: | 9072288468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 03/05/2010 | ||||||||
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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 | 363LX0001X | 82 AND 10053 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 367A00000X | 82 AND 10053 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | NP0082 | 05 | AK | MEDICAID |