Provider Demographics
NPI:1174858690
Name:MARTIN, ADAM PATRICK (DPT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:PATRICK
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 BETHPAGE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-9577
Mailing Address - Country:US
Mailing Address - Phone:208-277-4920
Mailing Address - Fax:
Practice Address - Street 1:411 E WATTS LN STE C
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4043
Practice Address - Country:US
Practice Address - Phone:208-277-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2577225100000X
SD1890225100000X
WAPT60124066225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1174858690Medicaid
ID808561200Medicaid
ID1174858690-001Medicaid
ID1652836Medicare PIN
WAG8893081Medicare PIN