Provider Demographics
NPI:1245777515
Name:MARTIN, THOMAS (RN)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20370 POE SHOLES DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7938
Mailing Address - Country:US
Mailing Address - Phone:541-318-1377
Mailing Address - Fax:541-383-4587
Practice Address - Street 1:20370 POE SHOLES DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7938
Practice Address - Country:US
Practice Address - Phone:541-318-1377
Practice Address - Fax:541-383-4587
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201400886RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse