Provider Demographics
NPI:1730227778
Name:ANDERSON, MARTIN LEE (PT)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 N 400 E
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1749
Mailing Address - Country:US
Mailing Address - Phone:435-713-9700
Mailing Address - Fax:435-753-8005
Practice Address - Street 1:169 SPRINGCREEK PKWY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9707
Practice Address - Country:US
Practice Address - Phone:435-755-8500
Practice Address - Fax:435-755-2836
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2850272401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT364291233000Medicaid
UTS74085Medicare UPIN