Basic Information
| Provider Information | |||||||||
| NPI: | 1992161244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10050 GREAT HILLS TRL | ||||||||
| Address2: | #1213 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787595938 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 928 W COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782074444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102611250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2015 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | TAP8335 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | AP130804 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | TAP8335 | 01 | AZ | AZ STATE BOARD OF NURSING - TYPE: TEMPORARY ADVANCED PRACTITIONER -SPECIALTY:FNP | OTHER |