Provider Demographics
NPI:1184612111
Name:MARTIN, LISA A (ARNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
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:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0333
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:515 S KINGS AVE STE 3100
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6060
Practice Address - Country:US
Practice Address - Phone:813-681-9171
Practice Address - Fax:813-681-7580
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN-3215122363LX0001X
FL104299531363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU51032Medicare UPIN