Provider Demographics
NPI:1730387051
Name:MARTIN, RUSSELL LEE (PA-C)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LEE
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 1:775 MOUNT VIEW RD
Mailing Address - Street 2:
Mailing Address - City:COOL RIDGE
Mailing Address - State:WV
Mailing Address - Zip Code:25825-9511
Mailing Address - Country:US
Mailing Address - Phone:304-228-0626
Mailing Address - Fax:
Practice Address - Street 1:200 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6444
Practice Address - Country:US
Practice Address - Phone:304-255-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-09
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVVADOOMedicare UPIN