Provider Demographics
NPI:1124378989
Name:MARTINEZ, CANDICE JANE (PA-C)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:JANE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:JANE
Other - Last Name:KOLB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4471 LONG PRAIRIE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1755
Mailing Address - Country:US
Mailing Address - Phone:972-316-4555
Mailing Address - Fax:505-938-4198
Practice Address - Street 1:1920 N COLLINS BLVD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080
Practice Address - Country:US
Practice Address - Phone:972-316-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08639363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant