Provider Demographics
NPI:1437695079
Name:MARTIN, RIA COSTALES (FNP)
Entity Type:Individual
Prefix:
First Name:RIA
Middle Name:COSTALES
Last Name:MARTIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:RIA
Other - Middle Name:SHARO
Other - Last Name:COSTALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5454 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3621
Practice Address - Country:US
Practice Address - Phone:619-515-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005321363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner