MEDICARE: MARTIN EDWARD SUDAR LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	7928	OR

General Provider Information

NPI Number	:	1407053796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTIN EDWARD SUDAR LPTA

Provider Business Mailing Address
First Line	:	3814 BOTTICELLI ST
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-1303
Country	:	US
Telephone Number	:	503-699-8128
Fax Number	:

Provider Business Practice Location Address
First Line	:	3814 BOTTICELLI ST
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-1303
Country	:	US
Telephone Number	:	503-699-8128
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	07/08/2007

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