Provider Demographics
NPI:1396398947
Name:COATES, MARTINEZ ANTUAN
Entity Type:Individual
Prefix:
First Name:MARTINEZ
Middle Name:ANTUAN
Last Name:COATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 PALM ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-4700
Mailing Address - Country:US
Mailing Address - Phone:702-808-1846
Mailing Address - Fax:
Practice Address - Street 1:1755 PALM ST BLD T APT147
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104
Practice Address - Country:UM
Practice Address - Phone:702-808-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2600245340103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth