Provider Demographics
NPI:1518084532
Name:MARTIN, MARY BETH (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 470408
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28247-0408
Mailing Address - Country:US
Mailing Address - Phone:704-375-0100
Mailing Address - Fax:704-375-8623
Practice Address - Street 1:7845 LITTLE AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8198
Practice Address - Country:US
Practice Address - Phone:704-375-0100
Practice Address - Fax:704-335-3599
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC135443363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003817Medicaid
NC7003817Medicaid