Provider Demographics
NPI:1073699096
Name:MARTIN, LAURA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARTIN
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-446-1422
Mailing Address - Fax:704-446-1582
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1422
Practice Address - Fax:704-446-1582
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102147363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1834PAMedicaid
202263OtherMEDCOST
NC8101152Medicaid
NC1073699096Medicaid
SC1834PAMedicaid
NC2770451Medicare PIN