Provider Demographics
NPI:1083091185
Name:MARTINEZ, CARA BOSCO (PA)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:BOSCO
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARA
Other - Middle Name:M
Other - Last Name:BOSCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4266 WOODLANDS LN
Mailing Address - Street 2:
Mailing Address - City:ORCHARD LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1675
Mailing Address - Country:US
Mailing Address - Phone:248-683-4266
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-631-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3979363A00000X
NC0010-06328363A00000X
MI5601006966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2596PAMedicaid
NC1083091185Medicaid
NCNCS216AMedicare PIN