Basic Information
| Provider Information | |||||||||
| NPI: | 1336132190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTMAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855800 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Practice Location | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855800 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1551261 | 05 | LA | MEDICAID |