MEDICARE: MS. SANDRA L MARTIN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	71001851A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000742868	OTHER	IN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	352145705	OTHER	IN	TAX ID

General Provider Information

NPI Number	:	1851373898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA L MARTIN NP

Provider Business Mailing Address
First Line	:	710 N NILES AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-1924
Country	:	US
Telephone Number	:	574-647-1610
Fax Number	:	574-237-6069

Provider Business Practice Location Address
First Line	:	100 NAVARRE PL
Second Line	:	SUITE 6600
City	:	SOUTH BEND
State	:	IN
Zip	:	46601-1156
Country	:	US
Telephone Number	:	574-232-7227
Fax Number	:	574-232-2064

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	03/30/2021

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