Provider Demographics
NPI:1851546469
Name:MARTIN, LAUREN E (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:E
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 1:100 WILLIAM NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-5407
Mailing Address - Country:US
Mailing Address - Phone:931-454-0489
Mailing Address - Fax:931-454-2348
Practice Address - Street 1:100 WILLIAM NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-5407
Practice Address - Country:US
Practice Address - Phone:931-454-0489
Practice Address - Fax:931-454-2348
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512147Medicaid
TN4314517OtherBCBS
103I974238Medicare PIN