Provider Demographics
NPI:1851373898
Name:MARTIN, SANDRA L (NP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:100 NAVARRE PL
Practice Address - Street 2:SUITE 6600
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1156
Practice Address - Country:US
Practice Address - Phone:574-232-7227
Practice Address - Fax:574-232-2064
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001851A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000742868OtherBCBS
IN200303930Medicaid
IN352145705OtherTAX ID
INQ37708Medicare UPIN
IN228750AMedicare ID - Type Unspecified
INM100032727Medicare PIN
IN352145705OtherTAX ID