Provider Demographics
NPI:1689748451
Name:WILLIAMS, MARTHA FAIR (PT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:FAIR
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 CERNON ST
Mailing Address - Street 2:SPORTREHAB PHYSICAL THERAPY
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-2803
Mailing Address - Country:US
Mailing Address - Phone:707-447-9750
Mailing Address - Fax:707-447-9220
Practice Address - Street 1:81 CERNON ST
Practice Address - Street 2:SPORTREHAB PHYSICAL THERAPY
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-2803
Practice Address - Country:US
Practice Address - Phone:707-447-9750
Practice Address - Fax:707-447-9220
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0097610Medicaid
CAPT0097610Medicaid
CAR27222Medicare UPIN