Provider Demographics
NPI:1275681306
Name:MARTINEZ, ELIZABETH ANNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-0670
Mailing Address - Country:US
Mailing Address - Phone:505-758-1970
Mailing Address - Fax:505-751-3031
Practice Address - Street 1:1400 WEIMER RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6346
Practice Address - Country:US
Practice Address - Phone:505-758-2073
Practice Address - Fax:505-751-3031
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78-PA006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant