Provider Demographics
NPI:1043659592
Name:MARTINEZ, LISA MARIE (CRNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GERGAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:3365 HIGH POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-7806
Mailing Address - Country:US
Mailing Address - Phone:610-954-5433
Mailing Address - Fax:610-691-1095
Practice Address - Street 1:3365 HIGH POINT BLVD
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-7806
Practice Address - Country:US
Practice Address - Phone:610-954-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007587363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1043659592Medicaid