Provider Demographics
NPI:1700825254
Name:MARTIN, WILLIAM R (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-474-2072
Mailing Address - Fax:
Practice Address - Street 1:101 W 8TH #L1
Practice Address - Street 2:STE 100
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2302
Practice Address - Country:US
Practice Address - Phone:509-474-2880
Practice Address - Fax:509-474-2241
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004582363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB32999OtherMEDICARE GROUP
WA8348252Medicaid
WAQ07535Medicare UPIN
WAG8864034Medicare PIN