Provider Demographics
NPI:1629514401
Name:MARTIN, SHELBY (ATC)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 CHRISTMAS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-3303
Mailing Address - Country:US
Mailing Address - Phone:952-412-1411
Mailing Address - Fax:
Practice Address - Street 1:5750 CHRISTMAS LAKE RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-3303
Practice Address - Country:US
Practice Address - Phone:952-412-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNFXF656A22785OtherANTHEM BLUE CROSS