Provider Demographics
NPI:1790705515
Name:MARTIN, MARIE B (PA C)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JOANNE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 124
Mailing Address - Street 2:
Mailing Address - City:MEDICINE BOW
Mailing Address - State:WY
Mailing Address - Zip Code:82329-0124
Mailing Address - Country:US
Mailing Address - Phone:307-378-2543
Mailing Address - Fax:
Practice Address - Street 1:514 IDAHO DRIVE
Practice Address - Street 2:
Practice Address - City:MEDICINE BOW
Practice Address - State:WY
Practice Address - Zip Code:82329-0037
Practice Address - Country:US
Practice Address - Phone:307-379-2222
Practice Address - Fax:307-279-2223
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY169363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY533803Medicare ID - Type Unspecified