Provider Demographics
NPI:1336415660
Name:MARTIN, GINA (LMT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-5313
Mailing Address - Country:US
Mailing Address - Phone:503-841-1165
Mailing Address - Fax:
Practice Address - Street 1:3990 ABBEY LN STE 101B
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-2237
Practice Address - Country:US
Practice Address - Phone:503-841-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17620174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1336415660Medicaid