Provider Demographics
NPI:1073902052
Name:MARTINEZ, ANNALISA JOANN (PA)
Entity Type:Individual
Prefix:MISS
First Name:ANNALISA
Middle Name:JOANN
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANNALISA
Other - Middle Name:
Other - Last Name:PALAZZOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1859
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:3601 W 13 MILE RD STE EC
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MI5601008621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical