Provider Demographics
NPI:1376500603
Name:MARTINEZ, JENNIFER L (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-1314
Mailing Address - Country:US
Mailing Address - Phone:620-672-7422
Mailing Address - Fax:
Practice Address - Street 1:203 WATSON ST
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-3066
Practice Address - Country:US
Practice Address - Phone:620-672-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500634363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS042310Medicare ID - Type Unspecified
KSS65690Medicare UPIN