Provider Demographics
NPI:1558399444
Name:MARTIN, SIDNEY A (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SIDNEY
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
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 677
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28093-0677
Mailing Address - Country:US
Mailing Address - Phone:704-735-3071
Mailing Address - Fax:704-735-0584
Practice Address - Street 1:200 GAMBLE DR
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4421
Practice Address - Country:US
Practice Address - Phone:704-735-3071
Practice Address - Fax:704-735-0584
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC048978367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8000175Medicaid
NC8000175Medicaid