Basic Information
| Provider Information | |||||||||
| NPI: | 1912001413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2309 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735022309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803555242 | ||||||||
| FaxNumber: | 5803555245 | ||||||||
| Practice Location | |||||||||
| Address1: | 5404 SW LEE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735059695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803555242 | ||||||||
| FaxNumber: | 5803555245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 85109 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.