Provider Demographics
NPI:1114793643
Name:CORDOVA, MARTINA SARA (FNP)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:SARA
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 GLADSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-1592
Mailing Address - Country:US
Mailing Address - Phone:650-455-1109
Mailing Address - Fax:
Practice Address - Street 1:15630 18TH AVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9336
Practice Address - Country:US
Practice Address - Phone:707-994-6486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026363363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily