Provider Demographics
NPI:1154887511
Name:MARTIN, KENNETH FREDRICK II (PT, DPT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:FREDRICK
Last Name:MARTIN
Suffix:II
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N BUFFALO DR STE 120
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-0397
Mailing Address - Country:US
Mailing Address - Phone:702-818-5000
Mailing Address - Fax:
Practice Address - Street 1:401 N BUFFALO DR STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0397
Practice Address - Country:US
Practice Address - Phone:702-818-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist