Provider Demographics
NPI:1356414643
Name:MARTIN, THOMAS ELIOT (RN, MSN, ACNP)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ELIOT
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RN, MSN, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:122 N BAILEY ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4202
Mailing Address - Country:US
Mailing Address - Phone:918-825-0216
Mailing Address - Fax:918-825-0216
Practice Address - Street 1:122 N BAILEY ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4202
Practice Address - Country:US
Practice Address - Phone:918-825-0216
Practice Address - Fax:918-825-0216
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRN71531363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP20205Medicare UPIN