Provider Demographics
NPI:1720184583
Name:MARTIN, ELLEN M (CRNA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 KAISER BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3341
Mailing Address - Country:US
Mailing Address - Phone:610-988-5089
Mailing Address - Fax:610-988-5135
Practice Address - Street 1:2603 KAISER BLVD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3341
Practice Address - Country:US
Practice Address - Phone:610-988-5089
Practice Address - Fax:610-988-5135
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN219942L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered