Provider Demographics
NPI:1043722432
Name:KISANG, MARTIN ASOBO
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:ASOBO
Last Name:KISANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SUMMIT TER APT 14
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2207
Mailing Address - Country:US
Mailing Address - Phone:720-448-0882
Mailing Address - Fax:
Practice Address - Street 1:4818 POINT FOSDICK DR NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1711
Practice Address - Country:US
Practice Address - Phone:253-851-3175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60791882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist