Provider Demographics
NPI:1215085956
Name:MARTIN, AVERY NICHOLAS (DC)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:NICHOLAS
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
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 508
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98235-0508
Mailing Address - Country:US
Mailing Address - Phone:360-856-5562
Mailing Address - Fax:360-856-4923
Practice Address - Street 1:22790 BUCHANAN STREET
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-856-5562
Practice Address - Fax:360-856-4923
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA33847111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8870740Medicare PIN
WA8870641Medicare PIN