Provider Demographics
NPI:1912027541
Name:MARTIN, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:S PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:S PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2432
Practice Address - Country:US
Practice Address - Phone:207-879-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2893225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant