Provider Demographics
NPI:1861652042
Name:MARTIN, VANESSA GAREN (ARNP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:GAREN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 POINT FOSDICK DR NW STE 319
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1731
Mailing Address - Country:US
Mailing Address - Phone:253-853-3888
Mailing Address - Fax:253-853-7393
Practice Address - Street 1:4700 POINT FOSDICK DR NW STE 319
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1731
Practice Address - Country:US
Practice Address - Phone:253-853-3888
Practice Address - Fax:253-853-7393
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007826363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1861652042Medicaid
WA025904OtherL&I KRMC GROUP NUMBER