Healthcare Provider Details

I. General information

NPI: 1366738056
Provider Name (Legal Business Name): DAVID M MARTIN AA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N209 HICKORY LN
WATERLOO WI
53594-9613
US

IV. Provider business mailing address

N209 HICKORY LN
WATERLOO WI
53594-9613
US

V. Phone/Fax

Practice location:
  • Phone: 920-650-5404
  • Fax:
Mailing address:
  • Phone: 920-650-5404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: