Provider Demographics
NPI:1912001413
Name:MARTINE, MICHAEL (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARTINE
Suffix:
Gender:M
Credentials:FNP
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 2309
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502-2309
Mailing Address - Country:US
Mailing Address - Phone:580-355-5242
Mailing Address - Fax:580-355-5245
Practice Address - Street 1:5404 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9695
Practice Address - Country:US
Practice Address - Phone:580-355-5242
Practice Address - Fax:580-355-5245
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK85109363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner