Provider Demographics
NPI:1619335379
Name:MARTIN, CONNIE I (CST)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:I
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 32530
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-2530
Mailing Address - Country:US
Mailing Address - Phone:602-222-2221
Mailing Address - Fax:602-266-2044
Practice Address - Street 1:1101 E MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2709
Practice Address - Country:US
Practice Address - Phone:602-222-2221
Practice Address - Fax:602-266-2044
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ122672246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ122672OtherCST CERTIFICATE NUMBER