Basic Information
| Provider Information | |||||||||
| NPI: | 1831789544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | TRAVIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 STONEY CREEK AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708088186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073504439 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 WAKE FOREST RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199543000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2021 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 6565 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.