Provider Demographics
NPI:1295998243
Name:MARTIN, WYNNE M (PT)
Entity type:Individual
Prefix:MRS
First Name:WYNNE
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17210 VAN WAGONER RD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9702
Mailing Address - Country:US
Mailing Address - Phone:616-296-2262
Mailing Address - Fax:616-935-3535
Practice Address - Street 1:17210 VAN WAGONER RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-296-2262
Practice Address - Fax:616-935-3535
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP14760007Medicare PIN