Provider Demographics
NPI:1508673971
Name:MARTIN, ROSS (BSN, RN)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-5769
Mailing Address - Country:US
Mailing Address - Phone:985-856-4462
Mailing Address - Fax:
Practice Address - Street 1:1627 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5769
Practice Address - Country:US
Practice Address - Phone:985-856-4462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA216163163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse