Provider Demographics
NPI:1821198839
Name:MARTIN, CYNTHIA SHACKLETON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:SHACKLETON
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3878 PINE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:WI
Mailing Address - Zip Code:54162-8827
Mailing Address - Country:US
Mailing Address - Phone:715-610-4067
Mailing Address - Fax:
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-433-8384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1359-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP43538Medicare UPIN