Provider Demographics
NPI:1912981267
Name:LATTA, MARTHA J (FNP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:LATTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:J
Other - Last Name:WOLFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:920 2ND AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-3318
Mailing Address - Country:US
Mailing Address - Phone:612-225-1512
Mailing Address - Fax:612-225-1593
Practice Address - Street 1:920 2ND AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402
Practice Address - Country:US
Practice Address - Phone:612-225-1512
Practice Address - Fax:612-225-1593
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN510498363LF0000X
CANPF7608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11117Medicare ID - Type UnspecifiedMEDICARE