Provider Demographics
NPI:1508529983
Name:MARTIN, LISA A
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
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 1:31312 E 683 RD
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-6304
Mailing Address - Country:US
Mailing Address - Phone:918-813-1005
Mailing Address - Fax:
Practice Address - Street 1:1219 W DUPONT ST
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5318
Practice Address - Country:US
Practice Address - Phone:918-341-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist