Provider Demographics
NPI:1972142669
Name:MARTIN, FITZ
Entity type:Individual
Prefix:
First Name:FITZ
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ALLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3645
Mailing Address - Country:US
Mailing Address - Phone:267-997-5272
Mailing Address - Fax:
Practice Address - Street 1:1055 E BALTIMORE PIKE STE 303
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5173
Practice Address - Country:US
Practice Address - Phone:610-892-3800
Practice Address - Fax:484-468-1412
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021299363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health