Provider Demographics
NPI:1265910293
Name:MIRISE, MARTIN PHILLIP (NURSE AIDE)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:PHILLIP
Last Name:MIRISE
Suffix:
Gender:M
Credentials:NURSE AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725-14TH ST. S.W.
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-5247
Mailing Address - Country:US
Mailing Address - Phone:330-454-8440
Mailing Address - Fax:
Practice Address - Street 1:1725-14TH ST. S.W.
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-5247
Practice Address - Country:US
Practice Address - Phone:330-454-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHODAPROV539434899374U00000X
OH400765940608376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPROV539434899OtherOHIO DEPT. OF AGING