Individual
TINA MARTIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
N.P.
Contact information
Practice address
2500 NORTH STATE STREET, JACKSON, MS 39216
(601) 984-5500
(601) 984-5499
Mailing address
PO BOX 4528, JACKSON, MS 39296-4528
(601) 984-5500
(601) 984-5499
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
325064-22
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00122593
—
MS
01
—
358766YKHV
MEDICARE ST DOM
MS
Enumeration date
07/31/2006
Last updated
07/20/2020
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