Active NPI
Tyler Martin, MA, ATC, LAT
- Athletic Trainer
- Kenosha, WI
National Provider Identifier
1043600919
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 1310-39
- Practice address
- 900 Wood Rd
Kenosha, WI 53144-1133 - Phone
- (262) 595-2164
- Fax
- (262) 595-2225
- NPI assigned
- Jan 30, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 1310-39 | WI | Primary |
Addresses
Primary practice location
900 Wood Rd
Kenosha, WI 53144-1133
Mailing address
1296 Village Centre Dr
Unit 5
Kenosha, WI 53144-7265
Phone (262) 515-1035
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2000003066 | Other | WI | NATABOC |
| 1310-39 | Other | WI | DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Master of Arts
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1310-39 | WI | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1422576000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1422576000000",
"number": "1043600919",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1296 VILLAGE CENTRE DR",
"address_2": "UNIT 5",
"city": "KENOSHA",
"state": "WI",
"postal_code": "531447265",
"telephone_number": "262-515-1035",
"fax_number": "262-595-2225"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "900 WOOD RD",
"city": "KENOSHA",
"state": "WI",
"postal_code": "531441133",
"telephone_number": "262-595-2164",
"fax_number": "262-595-2225"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MARTIN",
"first_name": "TYLER",
"name_prefix": "Mr.",
"credential": "MA, ATC, LAT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-01-30",
"last_updated": "2015-01-30",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "WI",
"license": "1310-39",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NATABOC",
"identifier": "2000003066",
"state": "WI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES",
"identifier": "1310-39",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Kenosha, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.