Provider Demographics
NPI:1669675914
Name:LIBERTY, MARTHA KINGMAN (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:KINGMAN
Last Name:LIBERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5939 HARRY HINES BLVD
Mailing Address - Street 2:POB II SUITE 603
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-0001
Mailing Address - Country:US
Mailing Address - Phone:214-645-5505
Mailing Address - Fax:214-645-5640
Practice Address - Street 1:5939 HARRY HINES BLVD
Practice Address - Street 2:POB II SUITE 603
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-0001
Practice Address - Country:US
Practice Address - Phone:214-645-5505
Practice Address - Fax:214-645-5640
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX557107363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP17921Medicare UPIN
TX85N359Medicare ID - Type Unspecified