Provider Demographics
NPI:1679600894
Name:LONGNER, MARTIN EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:EDWARD
Last Name:LONGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 HIGHWAY 95 STE 8
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8175
Mailing Address - Country:US
Mailing Address - Phone:928-763-9333
Mailing Address - Fax:928-763-9313
Practice Address - Street 1:3712 HIGHWAY 95 STE 8
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8175
Practice Address - Country:US
Practice Address - Phone:928-763-9333
Practice Address - Fax:928-763-9313
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU83530Medicare UPIN
AZ64144Medicare ID - Type Unspecified