Healthcare Provider Details

I. General information

NPI: 1023658424
Provider Name (Legal Business Name): AMBER MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 N 22ND WEST PL
SPERRY OK
74073-4141
US

IV. Provider business mailing address

9201 N 22ND WEST PL
SPERRY OK
74073-4141
US

V. Phone/Fax

Practice location:
  • Phone: 928-727-2424
  • Fax:
Mailing address:
  • Phone: 928-727-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: