Provider Demographics
NPI:1164008223
Name:MARTIN, FENIX R (DNP)
Entity Type:Individual
Prefix:DR
First Name:FENIX
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 S. ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:520-228-2628
Mailing Address - Fax:
Practice Address - Street 1:355TH MEDICAL GROUP
Practice Address - Street 2:4175 S. ALAMO AVE
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85707
Practice Address - Country:US
Practice Address - Phone:520-228-2628
Practice Address - Fax:520-228-8890
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR038864163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR038864Medicaid