Provider Demographics
NPI:1467598359
Name:MARTIN, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 WARDEN RD STE 230
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-6068
Mailing Address - Country:US
Mailing Address - Phone:501-392-9180
Mailing Address - Fax:
Practice Address - Street 1:6020 WARDEN RD STE 230
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120
Practice Address - Country:US
Practice Address - Phone:501-392-9180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1238261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145409721Medicaid
AR5W666OtherBLUE CROSS BLUE SHEILD