Provider Demographics
NPI:1376966689
Name:MARTIN, CHARLES (RN)
Entity Type:Individual
Prefix:
First Name:CHARLES
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 1:6348 ALUM RIDGE RD NW
Mailing Address - Street 2:
Mailing Address - City:RINER
Mailing Address - State:VA
Mailing Address - Zip Code:24149-3624
Mailing Address - Country:US
Mailing Address - Phone:540-763-2760
Mailing Address - Fax:
Practice Address - Street 1:8400 LEE HIGHWAY
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301
Practice Address - Country:US
Practice Address - Phone:540-994-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001238417163W00000X, 163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical