Provider Demographics
NPI:1538159298
Name:MARTIN, LORI LOUISE (PAC)
Entity type:Individual
Prefix:MISS
First Name:LORI
Middle Name:LOUISE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:797 S FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2617
Mailing Address - Country:US
Mailing Address - Phone:310-621-6439
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:PRIMARY CARE CLINIC RM 330
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1602
Practice Address - Country:US
Practice Address - Phone:757-314-7613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15787363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical