Provider Demographics
NPI:1740265297
Name:WILSON, MARTHA L (PT)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:L
Other - Last Name:SZAFRANIEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5753
Mailing Address - Country:US
Mailing Address - Phone:920-430-4750
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018168225100000X
WI4857225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400119815Medicare Oscar/Certification
WI330000029Medicare Oscar/Certification
WI073050047Medicare Oscar/Certification
WI073550095Medicare Oscar/Certification
WI075100096Medicare Oscar/Certification
WI802100030Medicare Oscar/Certification
WI073100047Medicare Oscar/Certification
WIP94830Medicare UPIN
WI002150210Medicare Oscar/Certification
WI100200051Medicare Oscar/Certification
WIK400234201Medicare Oscar/Certification