Provider Demographics
NPI:1396237210
Name:MARTIN, SUEZANNE K (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:SUEZANNE
Middle Name:K
Last Name:MARTIN
Suffix:
Gender:F
Credentials:AGACNP-BC
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 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-315-7910
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:1233 N MAIN ST STE 1A
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85336
Practice Address - Country:US
Practice Address - Phone:928-550-5514
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11333363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care