Provider Demographics
NPI:1003969585
Name:MARTIN, WALTER A (CRNA)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E ANTIETAM ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5724
Mailing Address - Country:US
Mailing Address - Phone:302-709-4497
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:251 E ANTIETAM ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5724
Practice Address - Country:US
Practice Address - Phone:302-709-4497
Practice Address - Fax:302-733-0854
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR148205367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR148205OtherLICENSE MARYLAND