Provider Demographics
NPI:1558080952
Name:MARTIN, MAUREEN PATRICIA
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:PATRICIA
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 1:1742 S OSBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-5720
Mailing Address - Country:US
Mailing Address - Phone:608-447-1071
Mailing Address - Fax:
Practice Address - Street 1:13035 W BLUEMOUND RD STE 100
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-8001
Practice Address - Country:US
Practice Address - Phone:262-794-1121
Practice Address - Fax:262-784-9777
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIM6355555994502OtherDRIVERS LICENSE