Provider Demographics
NPI:1285698167
Name:MAXWELL, MARTHA LEWIS (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:LEWIS
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:MARTHA
Other - Middle Name:LEE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 2668
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2668
Mailing Address - Country:US
Mailing Address - Phone:985-230-2198
Mailing Address - Fax:985-230-2159
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-230-1682
Practice Address - Fax:985-230-1617
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP01339367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
430035507OtherRR MEDICARE#
LA1399582Medicaid
59868Medicare ID - Type Unspecified