Provider Demographics
NPI:1295843704
Name:MARTINEZ, MARYANNE (PA C)
Entity Type:Individual
Prefix:MS
First Name:MARYANNE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
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 1:7000 SW 62ND AVE STE 525
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4721
Mailing Address - Country:US
Mailing Address - Phone:305-665-8188
Mailing Address - Fax:305-668-7706
Practice Address - Street 1:7000 SW 62ND AVE STE 525
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4721
Practice Address - Country:US
Practice Address - Phone:305-665-8188
Practice Address - Fax:305-668-7706
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102097363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291824200Medicaid
FL1044212OtherCAREPLUS
FL1044212OtherCAREPLUS