Provider Demographics
NPI:1639178874
Name:MARTIN, TERRY A (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRY
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 1:915 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:KS
Mailing Address - Zip Code:67835-9262
Mailing Address - Country:US
Mailing Address - Phone:620-855-7208
Mailing Address - Fax:
Practice Address - Street 1:100 W ROSS BLVD
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-7216
Practice Address - Country:US
Practice Address - Phone:620-225-2847
Practice Address - Fax:620-225-7046
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54522367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS057273Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE