Healthcare Provider Details

I. General information

NPI: 1104588813
Provider Name (Legal Business Name): LAUREN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2021
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W LEXINGTON ST
BALTIMORE MD
21201-1508
US

IV. Provider business mailing address

664 HEATHWALK MEWS
GAITHERSBURG MD
20878-6471
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-3100
  • Fax:
Mailing address:
  • Phone: 301-785-7175
  • Fax: 301-897-8597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: