Provider Demographics
NPI:1053396101
Name:MARTIN, KRISTIE COLLINS (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:COLLINS
Last Name:MARTIN
Suffix:
Gender:F
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 1:460 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-9494
Mailing Address - Country:US
Mailing Address - Phone:910-671-3200
Mailing Address - Fax:
Practice Address - Street 1:460 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28360-9494
Practice Address - Country:US
Practice Address - Phone:910-671-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000103914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC103914Medicaid
NC103914OtherNC LICENSE