Provider Demographics
NPI:1114974714
Name:MARTIN, ROSEANNE MARIE (ND)
Entity Type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7403
Mailing Address - Country:US
Mailing Address - Phone:503-665-9111
Mailing Address - Fax:503-665-0110
Practice Address - Street 1:119 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7403
Practice Address - Country:US
Practice Address - Phone:503-665-9111
Practice Address - Fax:503-665-0110
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1079175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182905Medicaid