Provider Demographics
NPI:1225369440
Name:MARTIN, PHILLIP A (CRNA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:SHADY VALLEY
Mailing Address - State:TN
Mailing Address - Zip Code:37688-5090
Mailing Address - Country:US
Mailing Address - Phone:423-844-2686
Mailing Address - Fax:423-844-2688
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-2686
Practice Address - Fax:423-844-2688
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA84226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I436556Medicare PIN