Provider Demographics
NPI:1255395679
Name:MARTIN, CHARLES ROBERT (PT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 KING COURT
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902
Mailing Address - Country:US
Mailing Address - Phone:509-248-6075
Mailing Address - Fax:509-457-8941
Practice Address - Street 1:3901 CREEKSIDE LOOP
Practice Address - Street 2:SUITE 102
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902
Practice Address - Country:US
Practice Address - Phone:509-248-6113
Practice Address - Fax:509-457-8941
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8343691Medicaid
WA186246OtherL AND I
WAAB03308Medicare ID - Type Unspecified