Provider Demographics
NPI:1861945719
Name:MARTIN, DESHAE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:DESHAE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 ROANOKE SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-6312
Mailing Address - Country:US
Mailing Address - Phone:813-585-7708
Mailing Address - Fax:
Practice Address - Street 1:110 LITHIA PINECREST RD STE B
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5300
Practice Address - Country:US
Practice Address - Phone:813-679-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9303768363LA2100X, 207RI0001X, 363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019436600Medicaid