Provider Demographics
NPI:1750686457
Name:KIRK, MARTHA W (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:W
Last Name:KIRK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:W
Other - Last Name:UDELHOFEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1821 S STOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2257
Mailing Address - Country:US
Mailing Address - Phone:608-260-6000
Mailing Address - Fax:608-260-6289
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2257
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:608-260-6289
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3248-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1750686457Medicaid
WIK400123946Medicare PIN