Provider Demographics
NPI:1730230418
Name:MARTIN, MICHEAL SHAWN (MPT,ATC,CSCS,PES)
Entity type:Individual
Prefix:MR
First Name:MICHEAL
Middle Name:SHAWN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MPT,ATC,CSCS,PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 W TUPELO WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6478
Mailing Address - Country:US
Mailing Address - Phone:479-200-1121
Mailing Address - Fax:
Practice Address - Street 1:3900 N PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6398
Practice Address - Country:US
Practice Address - Phone:479-966-4187
Practice Address - Fax:479-967-9658
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2890225100000X
AR2342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer