Provider Demographics
NPI:1831364793
Name:MARTIN, TONYA LYNN
Entity type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 JANETTE ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-3717
Mailing Address - Country:US
Mailing Address - Phone:501-318-5285
Mailing Address - Fax:501-318-5285
Practice Address - Street 1:107 JANETTE ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-3717
Practice Address - Country:US
Practice Address - Phone:501-318-5285
Practice Address - Fax:501-318-5285
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR160021783171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160021783Medicaid