Provider Demographics
NPI:1396419396
Name:MARTINEZ, JOSUE MARCO
Entity Type:Individual
Prefix:
First Name:JOSUE
Middle Name:MARCO
Last Name:MARTINEZ
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 1:6170 BOULDER HWY APT 1051
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-7708
Mailing Address - Country:US
Mailing Address - Phone:702-287-9714
Mailing Address - Fax:
Practice Address - Street 1:6170 BOULDER HWY APT 1051
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-7708
Practice Address - Country:US
Practice Address - Phone:702-287-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1487056909Medicaid