Provider Demographics
NPI:1053164871
Name:ISAZA DE RAMIREZ, MARTHA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:ISAZA DE RAMIREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 SOMERHILL DR NE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3465
Mailing Address - Country:US
Mailing Address - Phone:346-313-0989
Mailing Address - Fax:
Practice Address - Street 1:515 SOMERHILL DR NE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-3465
Practice Address - Country:US
Practice Address - Phone:346-313-0989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37694534172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver