Provider Demographics
NPI:1902374879
Name:MARTZ, ANNA MIRIA (APRN)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MIRIA
Last Name:MARTZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-1235
Mailing Address - Fax:
Practice Address - Street 1:125 S 20TH ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7100
Practice Address - Country:US
Practice Address - Phone:270-575-3247
Practice Address - Fax:270-908-4110
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100583380Medicaid