Healthcare Provider Details

I. General information

NPI: 1245568922
Provider Name (Legal Business Name): SHONDA LYNNETTE MARTIN LSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date: 10/04/2010
Reactivation Date: 10/19/2010

III. Provider practice location address

1 SUGAR CREEK CENTER BLVD STE 618
SUGAR LAND TX
77478-3560
US

IV. Provider business mailing address

1 SUGAR CREEK CENTER BLVD STE 618
SUGAR LAND TX
77478-3560
US

V. Phone/Fax

Practice location:
  • Phone: 832-655-4141
  • Fax: 713-457-5188
Mailing address:
  • Phone: 832-655-4141
  • Fax: 713-457-5188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberSA00438
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00438
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: