Provider Demographics
NPI:1417670449
Name:MARTIN, MARIA RAVKATOVNA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:RAVKATOVNA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:RAVKATOVNA
Other - Last Name:SULTANSHINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:539 N. WESTORER BLVD
Mailing Address - Street 2:AP 4101
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707
Mailing Address - Country:US
Mailing Address - Phone:229-854-4670
Mailing Address - Fax:
Practice Address - Street 1:1201 GRANT BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104
Practice Address - Country:US
Practice Address - Phone:314-257-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN252454363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care