Healthcare Provider Details

I. General information

NPI: 1417302936
Provider Name (Legal Business Name): STEPHEN CHRISTOPHER MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13805 53RD AVE N APT 6 UNITED STATES
PLYMOUTH MN
55446-1897
US

IV. Provider business mailing address

13805 53RD AVE N APT 6 UNITED STATES
PLYMOUTH MN
55446-1897
US

V. Phone/Fax

Practice location:
  • Phone: 763-260-7649
  • Fax:
Mailing address:
  • Phone: 763-260-7649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246Y00000X
TaxonomyHealth Information Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: