Provider Demographics
NPI:1215165766
Name:MARTIN, LAURA C (CRNA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNA
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 4985
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32802-4985
Mailing Address - Country:US
Mailing Address - Phone:407-581-9180
Mailing Address - Fax:407-926-9173
Practice Address - Street 1:400 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5722
Practice Address - Country:US
Practice Address - Phone:407-581-9180
Practice Address - Fax:407-926-9173
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9213886367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
XXX-XX-6273OtherCHAMPUS TRICARE - SOUTH REGION
P00758247OtherRAILROAD MEDICARE
FL0013550 00Medicaid
FLG002JOtherBCBS
FL0013550 00Medicaid