Healthcare Provider Details

I. General information

NPI: 1336705490
Provider Name (Legal Business Name): MARTHA MARIE TAYLOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARTHA MARIE SMITH

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 S RIDGE RD
GREEN BAY WI
54304-4125
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4888
  • Fax: 920-430-4889
Mailing address:
  • Phone: 920-445-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13156
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5583-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: