1730420134 NPI number — LISA MARIE MARTIN LAC, EAMP, AC

Table of content: LISA MARIE MARTIN LAC, EAMP, AC (NPI 1730420134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730420134 NPI number — LISA MARIE MARTIN LAC, EAMP, AC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
LISA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC, EAMP, AC
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:
1730420134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5407 21ST AVENUE CT NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98422-1959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-459-3704
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 AUBURN WAY N STE A1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98002-5062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-394-1466
Provider Business Practice Location Address Fax Number:
253-275-5047
Provider Enumeration Date:
03/09/2013

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: 171100000X , with the licence number:  AC60316469 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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