Healthcare Provider Details

I. General information

NPI: 1659163269
Provider Name (Legal Business Name): CHRISTIAN OMAR MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 W AMERICAN DR
NEENAH WI
54956-1405
US

IV. Provider business mailing address

2070 E PLANK RD UNIT 2
APPLETON WI
54915-7052
US

V. Phone/Fax

Practice location:
  • Phone: 920-727-8144
  • Fax: 920-569-3793
Mailing address:
  • Phone: 920-944-5905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4261-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: