Provider Demographics
NPI:1558527333
Name:MARTIN, WILLARD FRASER II
Entity Type:Individual
Prefix:
First Name:WILLARD
Middle Name:FRASER
Last Name:MARTIN
Suffix:II
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 1:16905 HOSKINSON RD
Mailing Address - Street 2:
Mailing Address - City:POOLESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20837-2280
Mailing Address - Country:US
Mailing Address - Phone:301-972-8509
Mailing Address - Fax:
Practice Address - Street 1:9901 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3357
Practice Address - Country:US
Practice Address - Phone:301-946-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000605363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMM0903244OtherDEA
MD1742403Y1ZMedicare PIN