Provider Demographics
NPI:1740894195
Name:MARTIN, GUNNAR
Entity type:Individual
Prefix:
First Name:GUNNAR
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 543
Mailing Address - Street 2:
Mailing Address - City:MAC ARTHUR
Mailing Address - State:WV
Mailing Address - Zip Code:25873-0543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:481 COAL RIVER RD
Practice Address - Street 2:
Practice Address - City:GLEN DANIEL
Practice Address - State:WV
Practice Address - Zip Code:25844-9403
Practice Address - Country:US
Practice Address - Phone:304-712-8589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide