Provider Demographics
NPI:1194857532
Name:MARTIN, PETER J
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MARTIN
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:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:TEKOA
Mailing Address - State:WA
Mailing Address - Zip Code:99033-0629
Mailing Address - Country:US
Mailing Address - Phone:509-284-2423
Mailing Address - Fax:509-284-3434
Practice Address - Street 1:N. 115 CROSBY
Practice Address - Street 2:
Practice Address - City:TEKOA
Practice Address - State:WA
Practice Address - Zip Code:99033-0629
Practice Address - Country:US
Practice Address - Phone:509-284-2423
Practice Address - Fax:509-284-3434
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025211PA10000093363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8349276Medicaid
503838Medicare Oscar/Certification