Provider Demographics
NPI:1386187623
Name:MARTINEZ, MARISOL HERNANDEZ (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARISOL
Middle Name:HERNANDEZ
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISOL
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 S ELISEO DR STE 1
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2017
Mailing Address - Country:US
Mailing Address - Phone:415-514-6868
Mailing Address - Fax:
Practice Address - Street 1:1100 S ELISEO DR STE 1
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2017
Practice Address - Country:US
Practice Address - Phone:415-514-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant