Provider Demographics
NPI:1790881175
Name:DUGANNE, MARTHA A (PT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:DUGANNE
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:PO BOX 4876
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502
Mailing Address - Country:US
Mailing Address - Phone:505-946-9335
Mailing Address - Fax:505-983-6243
Practice Address - Street 1:1700 CERRILLOS RD.
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-946-9335
Practice Address - Fax:505-983-6243
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00076797Medicaid