Provider Demographics
NPI:1477000248
Name:MARTIN, TAMARA
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 WESTFIELD DR STE 1
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-1005
Practice Address - Country:US
Practice Address - Phone:419-445-2015
Practice Address - Fax:419-445-8102
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019854363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily