Provider Demographics
NPI:1942586771
Name:MARTIN, LIZBETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LIZBETH
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LIZBETH
Other - Middle Name:
Other - Last Name:GASTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3131 INNOVATION DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6501
Mailing Address - Country:US
Mailing Address - Phone:407-498-0071
Mailing Address - Fax:407-498-0073
Practice Address - Street 1:3131 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6501
Practice Address - Country:US
Practice Address - Phone:407-498-0071
Practice Address - Fax:407-498-0073
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2216363A00000X
FLPA9106466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003120311AMedicaid
GA003120311AMedicaid