Provider Demographics
NPI:1306244595
Name:BREA, MARTIN (MA ATC LAT)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:BREA
Suffix:
Gender:M
Credentials:MA ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-3336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 WILSON AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-3336
Practice Address - Country:US
Practice Address - Phone:724-223-3262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-20
Last Update Date:2014-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART000246A282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA812335OtherCERTIFIED ATHLETIC TRAINER