Provider Demographics
NPI:1508310400
Name:MARTAN, EDGARDO (PTA)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:MARTAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2500 N SILVERBELL RD
Practice Address - Street 2:STE. 150
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-7062
Practice Address - Country:US
Practice Address - Phone:520-624-2999
Practice Address - Fax:520-305-4719
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11290A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant