Healthcare Provider Details

I. General information

NPI: 1245777515
Provider Name (Legal Business Name): THOMAS MARTIN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20370 POE SHOLES DR
BEND OR
97703-7938
US

IV. Provider business mailing address

20370 POE SHOLES DR
BEND OR
97703-7938
US

V. Phone/Fax

Practice location:
  • Phone: 541-318-1377
  • Fax: 541-383-4587
Mailing address:
  • Phone: 541-318-1377
  • Fax: 541-383-4587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201400886RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: