Healthcare Provider Details

I. General information

NPI: 1447887005
Provider Name (Legal Business Name): SETH MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11324 CITRA CIR APT 103
WINDERMERE FL
34786-5950
US

IV. Provider business mailing address

11324 CITRA CIR APT 103
WINDERMERE FL
34786-5950
US

V. Phone/Fax

Practice location:
  • Phone: 318-207-8552
  • Fax:
Mailing address:
  • Phone: 318-207-8552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1000030
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN9459855
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: