Basic Information
| Provider Information | |||||||||
| NPI: | 1053320663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | CNS, APRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6025 LAKE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519996800 | ||||||||
| FaxNumber: | 6519996830 | ||||||||
| Practice Location | |||||||||
| Address1: | 6025 LAKE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519996800 | ||||||||
| FaxNumber: | 6519996830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | R115050-6 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 364S00000X | CNS0091 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | 924907000 | 05 | MN | MEDICAID |