Provider Demographics
NPI:1295854560
Name:HYATT, MARTHA GRAY (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:GRAY
Last Name:HYATT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8585 SW CANYON LN APT 7
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-3956
Mailing Address - Country:US
Mailing Address - Phone:503-296-9478
Mailing Address - Fax:
Practice Address - Street 1:8585 SW CANYON LN APT 7
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-3956
Practice Address - Country:US
Practice Address - Phone:503-296-9478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10743174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist