Healthcare Provider Details

I. General information

NPI: 1437200219
Provider Name (Legal Business Name): MR. TIMOTHY WALTER MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 VAIL AVE ANESTHESIA DEPARTMENT
CHARLOTTE NC
28207-1219
US

IV. Provider business mailing address

PO BOX 60499 ANESTHESIA DEPARTMENT
CHARLOTTE NC
28260-0499
US

V. Phone/Fax

Practice location:
  • Phone: 704-304-5995
  • Fax:
Mailing address:
  • Phone: 704-304-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number176128
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: