Healthcare Provider Details

I. General information

NPI: 1639850837
Provider Name (Legal Business Name): MATTHEW KURT MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S LOS ROBLES AVE # 501
PASADENA CA
91101-2453
US

IV. Provider business mailing address

2006 HOGBACK RD
ANN ARBOR MI
48105-9750
US

V. Phone/Fax

Practice location:
  • Phone: 626-564-3016
  • Fax:
Mailing address:
  • Phone: 734-263-2417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704346487
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: