Basic Information
| Provider Information | |||||||||
| NPI: | 1558863068 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | LUCAS | ||||||||
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| Credential: | APRN, FNP-C, ENP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 S WEATHERRED DR | ||||||||
| Address2: | |||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750806021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176881769 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | UT SOUTHWESTERN DEPARTMENT EMERGENCY MEDICINE | ||||||||
| Address2: | 5323 HARRY HINES BLVD | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753908579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146483916 | ||||||||
| FaxNumber: | 2146488423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 854402 | TX | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP136590 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.