Provider Demographics
NPI:1336463355
Name:MARTIN, MARLO C (CRNA)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2248
Mailing Address - Country:US
Mailing Address - Phone:225-293-2523
Mailing Address - Fax:225-293-1807
Practice Address - Street 1:100 WOMANS WAY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-5100
Practice Address - Country:US
Practice Address - Phone:225-293-2523
Practice Address - Fax:225-293-1807
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN114386 AP06025367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LARN114386 AP06025OtherLA LIC