Provider Demographics
NPI:1215116876
Name:MARTIN, DODIE LANE (PA-C)
Entity type:Individual
Prefix:MS
First Name:DODIE
Middle Name:LANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
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 520
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:KS
Mailing Address - Zip Code:67548-0520
Mailing Address - Country:US
Mailing Address - Phone:785-222-2564
Mailing Address - Fax:785-222-2868
Practice Address - Street 1:801 LOCUST ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:KS
Practice Address - Zip Code:67548-9673
Practice Address - Country:US
Practice Address - Phone:785-222-2564
Practice Address - Fax:785-222-2868
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01190363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant