Provider Demographics
NPI:1083637680
Name:MARTINEZ, KIMBERLY MARIE (ANP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SE STRATUS AVE UNIT 304
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6257
Mailing Address - Country:US
Mailing Address - Phone:503-434-6090
Mailing Address - Fax:503-474-3306
Practice Address - Street 1:2700 SE STRATUS AVE UNIT 304
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6257
Practice Address - Country:US
Practice Address - Phone:503-434-6090
Practice Address - Fax:503-474-3306
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR094006411N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210707Medicaid
OR13-4231448Medicare UPIN
OR210707Medicaid