Provider Demographics
NPI:1144542457
Name:MARTIN, BRIAN T (PA)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:T
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD STE 1234
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6355
Practice Address - Country:US
Practice Address - Phone:208-429-0300
Practice Address - Fax:208-429-0305
Is Sole Proprietor?:No
Enumeration Date:2010-02-28
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1767363A00000X
CAPA21543363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-1767Medicaid
SCP00886826OtherRAILROAD MC ID-RSFPN
SC0969PAMedicaid