Provider Demographics
NPI:1962600288
Name:MARTIN, MICHAEL WARREN (PBT (ASCP))
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PBT (ASCP)
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 141642
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99514-1642
Mailing Address - Country:US
Mailing Address - Phone:907-952-3117
Mailing Address - Fax:800-660-0768
Practice Address - Street 1:4412 AMES AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-1702
Practice Address - Country:US
Practice Address - Phone:907-952-3117
Practice Address - Fax:800-660-0768
Is Sole Proprietor?:No
Enumeration Date:2007-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4344382083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine