Provider Demographics
NPI:1730153719
Name:MARTIN, MATTHEW ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8905
Mailing Address - Fax:765-939-4200
Practice Address - Street 1:1400 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-8809
Practice Address - Country:US
Practice Address - Phone:765-935-8905
Practice Address - Fax:765-939-4200
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002450363A00000X
IN10000584A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000767410OtherANTHEM - RPA
INOPRMedicaid
OH0110849Medicaid
OHH097790Medicare PIN
000000767410OtherANTHEM - RPA