Provider Demographics
NPI:1245568922
Name:MARTIN, SHONDA LYNNETTE (LSA)
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:LYNNETTE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SUGAR CREEK CENTER BLVD STE 618
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3560
Mailing Address - Country:US
Mailing Address - Phone:832-655-4141
Mailing Address - Fax:713-457-5188
Practice Address - Street 1:1 SUGAR CREEK CENTER BLVD STE 618
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3560
Practice Address - Country:US
Practice Address - Phone:832-655-4141
Practice Address - Fax:713-457-5188
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2015-05-05
Deactivation Date:2010-10-04
Deactivation Code:
Reactivation Date:2010-10-19
Provider Licenses
StateLicense IDTaxonomies
TXSA00438363AS0400X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81NN51OtherBCBS
TX81NN50OtherBCBS