Healthcare Provider Details

I. General information

NPI: 1619546975
Provider Name (Legal Business Name): SYDNEY MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTH STADIUM ROAD
BATON ROUGE LA
70803-0001
US

IV. Provider business mailing address

101 RIVER HOUSE PL APT 1210
BATON ROUGE LA
70802-7670
US

V. Phone/Fax

Practice location:
  • Phone: 225-578-2050
  • Fax:
Mailing address:
  • Phone: 702-205-0018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: