Provider Demographics
NPI:1871666727
Name:MARTIN, PEGGY SUE (PT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:SUE
Other - Last Name:AIKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:888-201-1040
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:1507 W KNAPP ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1383
Practice Address - Country:US
Practice Address - Phone:877-823-0508
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02104225100000X
WI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871666727Medicaid
800500016Medicare PIN