Provider Demographics
NPI:1104217207
Name:MARTIN, WILLIAM (MS,ATC,CSCS,LAT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MS,ATC,CSCS,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4186 E BLUE SAGE RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-4934
Mailing Address - Country:US
Mailing Address - Phone:480-338-8710
Mailing Address - Fax:
Practice Address - Street 1:4186 E BLUE SAGE RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-4934
Practice Address - Country:US
Practice Address - Phone:480-338-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer