=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821507534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA LINN MARTIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2017
-----------------------------------------------------
Last Update Date | 10/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24700 LORAIN RD STE 207
-----------------------------------------------------
City | NORTH OLMSTED
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44070-2068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-779-5505
-----------------------------------------------------
Fax | 440-779-1342
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 918 TIMOTHY LN
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-3737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-630-4419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------