Provider Demographics
NPI:1285163774
Name:MARTIN, NADINE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 21ST ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-4501
Mailing Address - Country:US
Mailing Address - Phone:720-289-0606
Mailing Address - Fax:
Practice Address - Street 1:311 MAPLETON AVE # 331
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304
Practice Address - Country:US
Practice Address - Phone:720-289-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA405200163W00000X
CA7458363L00000X
COAPN.0993533-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
COAPN.0993533-NPOtherCOLORADO DIVISION OF REGULATED AGENCIES
CA405200OtherREGISTERED NURSE LICENSE