Provider Demographics
NPI:1144748179
Name:CURTIN, MARTHA AGNES
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:AGNES
Last Name:CURTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3631
Mailing Address - Country:US
Mailing Address - Phone:618-942-2174
Mailing Address - Fax:618-988-6166
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:708-269-3475
Practice Address - Fax:708-269-3475
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMULTISPECIALTY GROUP PTAN