Provider Demographics
NPI:1073701116
Name:MARTINSON, DUSTIN DARYL (PT)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:DARYL
Last Name:MARTINSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 E BOXELDER RD
Mailing Address - Street 2:STE U
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5582
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-288-0424
Practice Address - Street 1:1103 E BOXELDER RD
Practice Address - Street 2:STE U
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5582
Practice Address - Country:US
Practice Address - Phone:307-686-8177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1215174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW21893OtherMEDICARE-NORIDIAN