1336463355 NPI number — MARLO C MARTIN CRNA

Table of content: DR. BAO LAN DUC PHAM M.D. (NPI 1326357856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336463355 NPI number — MARLO C MARTIN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
MARLO
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336463355
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2644 S SHERWOOD FOREST BLVD
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-2248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-293-2523
Provider Business Mailing Address Fax Number:
225-293-1807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 WOMANS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70817-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-293-2523
Provider Business Practice Location Address Fax Number:
225-293-1807
Provider Enumeration Date:
03/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN114386 AP06025 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN114386 AP06025 . This is a "LA LIC" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com