Provider Demographics
NPI:1407554702
Name:MARTINEZ LEDESMA, ROBERTO (PA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:MARTINEZ LEDESMA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BARK BEND PL
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 BARK BEND PL
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77385-3755
Practice Address - Country:US
Practice Address - Phone:305-834-9702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant