Provider Demographics
NPI:1790340552
Name:MARTIN, STEPHANIE LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 TOWN CENTRE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1370
Mailing Address - Country:US
Mailing Address - Phone:612-871-1145
Mailing Address - Fax:
Practice Address - Street 1:1185 TOWN CENTRE DR STE 205
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1370
Practice Address - Country:US
Practice Address - Phone:612-871-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4669-23363A00000X
MN13826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790340552Medicaid