Basic Information
| Provider Information | |||||||||
| NPI: | 1437600012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ALEXANDER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 44TH ST SE | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495085006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177876440 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 JEFFERSON AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166855000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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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 | 367500000X | 4704282016 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.