Provider Demographics
NPI:1124030168
Name:MARTIN, NICHOLAS J (LPT, PT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 PENCO RD
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062
Mailing Address - Country:US
Mailing Address - Phone:304-723-3780
Mailing Address - Fax:304-723-4110
Practice Address - Street 1:1425 MAIN ST
Practice Address - Street 2:
Practice Address - City:FOLLANSBEE
Practice Address - State:WV
Practice Address - Zip Code:26037-1217
Practice Address - Country:US
Practice Address - Phone:304-527-4472
Practice Address - Fax:304-527-4648
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001084225100000X
OHPT007091225100000X
PAPT006744L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV55071930003OtherTHE HEALTH PLAN BWC
WV1515473000OtherUS DEPT OF LABOR
WV55071930000OtherWV WORKERS COMP BRICKSTEE
000745333OtherBLUE CROSS/BLUE SHIELD
WV0156604000Medicaid
WV0735024Medicare PIN
WV1515473000OtherUS DEPT OF LABOR