Provider Demographics
NPI:1992014898
Name:KOGLIN, MARTHA E (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:KOGLIN
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 1:24 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PORT AUSTIN
Mailing Address - State:MI
Mailing Address - Zip Code:48467-6736
Mailing Address - Country:US
Mailing Address - Phone:989-738-5222
Mailing Address - Fax:989-738-5224
Practice Address - Street 1:24 E SPRING ST
Practice Address - Street 2:
Practice Address - City:PORT AUSTIN
Practice Address - State:MI
Practice Address - Zip Code:48467-6736
Practice Address - Country:US
Practice Address - Phone:989-738-5222
Practice Address - Fax:989-738-5224
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005895363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant