Provider Demographics
NPI:1689452583
Name:MARTIN, JAMES ANGUS
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ANGUS
Last Name:MARTIN
Suffix:
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 1:130 S WILLOW ST STE 9
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-9107
Mailing Address - Country:US
Mailing Address - Phone:907-283-0085
Mailing Address - Fax:907-283-0084
Practice Address - Street 1:130 S WILLOW ST STE 9
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-9107
Practice Address - Country:US
Practice Address - Phone:907-283-0085
Practice Address - Fax:907-283-0084
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK17123593747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1712359Medicaid