Provider Demographics
NPI:1992161244
Name:MARTIN, MELISSA DIANE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10050 GREAT HILLS TRL
Mailing Address - Street 2:#1213
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-4444
Practice Address - Country:US
Practice Address - Phone:210-261-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-31
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP8335363LF0000X
TXAP130804363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZTAP8335OtherAZ STATE BOARD OF NURSING - TYPE: TEMPORARY ADVANCED PRACTITIONER -SPECIALTY:FNP