Basic Information
| Provider Information | |||||||||
| NPI: | 1538601166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANKHEAD | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE | ||||||||
| Address2: | DEPT. 358 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986839324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 390 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974399470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419977134 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2016 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60826975 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA180422 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.