Provider Demographics
NPI:1043600919
Name:MARTIN, TYLER (MA, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1296 VILLAGE CENTRE DR
Mailing Address - Street 2:UNIT 5
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-7265
Mailing Address - Country:US
Mailing Address - Phone:262-515-1035
Mailing Address - Fax:262-595-2225
Practice Address - Street 1:900 WOOD RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1133
Practice Address - Country:US
Practice Address - Phone:262-595-2164
Practice Address - Fax:262-595-2225
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1310-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2000003066OtherNATABOC
WI1310-39OtherDEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES