Provider Demographics
NPI:1174982045
Name:SIDWELL, MARTI JO
Entity type:Individual
Prefix:
First Name:MARTI
Middle Name:JO
Last Name:SIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTI
Other - Middle Name:JO
Other - Last Name:TYLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:688 ANTELOPE DR LOT 21
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-3016
Mailing Address - Country:US
Mailing Address - Phone:307-274-7500
Mailing Address - Fax:
Practice Address - Street 1:400 N 100 E
Practice Address - Street 2:SUITE 205
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935
Practice Address - Country:US
Practice Address - Phone:307-362-2424
Practice Address - Fax:307-222-0614
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management