Provider Demographics
NPI:1437200219
Name:MARTIN, TIMOTHY WALTER
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:WALTER
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 60499
Mailing Address - Street 2:ANESTHESIA DEPARTMENT
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0499
Mailing Address - Country:US
Mailing Address - Phone:704-304-6202
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1219
Practice Address - Country:US
Practice Address - Phone:704-304-5995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC176128367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052812Medicaid
SCNAN760Medicaid
SCNAN760Medicaid