Provider Demographics
NPI:1336705490
Name:TAYLOR, MARTHA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:MARIE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:
Practice Address - Street 1:1970 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4125
Practice Address - Country:US
Practice Address - Phone:920-430-4888
Practice Address - Fax:920-430-4889
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MN13156363A00000X
WI5583-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer