Provider Demographics
NPI:1508104001
Name:MARTIN, MIA CARROLL (RN, CPNP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:CARROLL
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 MEDICAL DISTRICT DR
Mailing Address - Street 2:CHILDREN'S MEDICAL CENTER
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7701
Mailing Address - Country:US
Mailing Address - Phone:806-786-3781
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:CHILDREN'S MEDICAL CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:806-786-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX720959363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics