Provider Demographics
NPI:1154308385
Name:MARTINEZ, KIMBERLY J (CRNA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:J
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:6606 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6524
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX580963367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166058102Medicaid
TX166058104Medicaid
TX8854UGOtherBCBS TX
TX166058106Medicaid
TXP00428313OtherRAILROAD MEDICARE
TX85453UOtherBCBS
TX166058106Medicaid
TX166058104Medicaid
TX340378YK6UMedicare PIN
TX8L23840Medicare PIN