Provider Demographics
NPI:1356819312
Name:MARTIN, JOSEPH ROBERT (ACNP)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ROBERT
Last Name:MARTIN
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 HEARNE AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3918
Mailing Address - Country:US
Mailing Address - Phone:318-631-6400
Mailing Address - Fax:318-631-0300
Practice Address - Street 1:2727 HEARNE AVE STE 301
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103
Practice Address - Country:US
Practice Address - Phone:318-631-6400
Practice Address - Fax:318-631-0300
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10022363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2488597Medicaid