Provider Demographics
NPI:1467678250
Name:MARTIN, CORAZON (PA)
Entity Type:Individual
Prefix:MS
First Name:CORAZON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CORY
Other - Middle Name:
Other - Last Name:MARTIN-VALDES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:5815 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-7107
Mailing Address - Country:US
Mailing Address - Phone:281-543-9458
Mailing Address - Fax:
Practice Address - Street 1:1708 ELMEN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77019-5702
Practice Address - Country:US
Practice Address - Phone:281-543-9458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1467678250OtherBLUE CROSS BLUE SHIELD
TX1467678250OtherTEXAS CHILDRENS HEALTH PLAN
TX1467678250Medicaid
TX1467678250OtherAMERIGROUP
TX1467678250OtherMOLINA HEALTHCARE
TX1467678250OtherEVERCARE
TX286580001Medicaid
TX1467678250Medicare PIN