Provider Demographics
NPI:1679649792
Name:MARTIN, MITCHELL LEE (PA)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:LEE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 W SAINT MARY BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3568
Mailing Address - Country:US
Mailing Address - Phone:337-269-0963
Mailing Address - Fax:337-269-0553
Practice Address - Street 1:439 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2616
Practice Address - Country:US
Practice Address - Phone:337-269-0963
Practice Address - Fax:337-269-0553
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAA10592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAQ09068Medicare UPIN
LA5M505P547Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER