Basic Information
| Provider Information | |||||||||
| NPI: | 1851407142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 KANAWHA AVE | ||||||||
| Address2: | |||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386188 | ||||||||
| FaxNumber: | 3044386819 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 KANAWHA AVE | ||||||||
| Address2: | |||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386188 | ||||||||
| FaxNumber: | 3044386819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 09/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 00965 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | ED0222A | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2635 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810024860 | 05 | WV | MEDICAID | 2744504 | 01 | WV | BC/BS | OTHER | 0034320000 | 05 | WV | MEDICAID | 0056758000 | 05 | WV | MEDICAID |