Provider Demographics
NPI:1932313608
Name:MARTIN, LAYNE C (ROT)
Entity Type:Individual
Prefix:
First Name:LAYNE
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:M
Credentials:ROT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 W 1700 S
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83346-9747
Mailing Address - Country:US
Mailing Address - Phone:208-862-0402
Mailing Address - Fax:
Practice Address - Street 1:1263 BENNETT AVE STE 1
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2666
Practice Address - Country:US
Practice Address - Phone:208-678-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID05070617246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist