Provider Demographics
NPI:1235719576
Name:MARTINEZ, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 LANCELOT WAY
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-3923
Mailing Address - Country:US
Mailing Address - Phone:407-456-3163
Mailing Address - Fax:
Practice Address - Street 1:1240 LANCELOT WAY
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-3923
Practice Address - Country:US
Practice Address - Phone:407-456-3163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113967363A00000X
NY026374-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant