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NPI Code Detail

MEDICARE: MISS LORI LOUISE MARTIN PAC

MEDICARE: MISS LORI LOUISE MARTIN PAC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician AssistantPA15787CA

General Provider Information

NPI Number : 1538159298
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS LORI LOUISE MARTIN PAC
Provider Business Mailing Address
First Line : 797 S FAIR OAKS AVE
Second Line :
City : PASADENA
State : CA
Zip : 91105-2617
Country : US
Telephone Number : 310-621-6439
Fax Number :
Provider Business Practice Location Address
First Line : 576 JEFFERSON AVE
Second Line : PRIMARY CARE CLINIC RM 330
City : FORT EUSTIS
State : VA
Zip : 23604-1602
Country : US
Telephone Number : 757-314-7613
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/25/2005
Last Update Date : 05/29/2014

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Directions to “ MISS LORI LOUISE MARTIN PAC” Practice Location

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