Provider Demographics
NPI:1265717250
Name:CODISPOTI, MARTIN L (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:L
Last Name:CODISPOTI
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5804
Practice Address - Street 1:122 NICK SAVAS DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3468
Practice Address - Country:US
Practice Address - Phone:304-752-8081
Practice Address - Fax:304-752-8083
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV73900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV0975EMedicare PIN
WVWV0975AMedicare PIN
WVWV0975B662Medicare PIN
WVWV0975DMedicare PIN
WVWV0975CMedicare PIN
WVWV0975BMedicare PIN
WVWV0975FMedicare PIN
WVWV0975GMedicare PIN
WVWV0975B663Medicare PIN
WVWV0975HMedicare PIN