Provider Demographics
NPI:1902964919
Name:MARTIN, REBECCA D (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:D
Other - Last Name:PORDES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:363 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3703
Practice Address - Country:US
Practice Address - Phone:508-973-5918
Practice Address - Fax:508-973-5916
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA1009363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S49384Medicare UPIN
MAAP2009Medicare ID - Type Unspecified