Provider Demographics
NPI:1497822142
Name:MARTINEZ, EZEQUIEL (PA)
Entity Type:Individual
Prefix:MR
First Name:EZEQUIEL
Middle Name:
Last Name:MARTINEZ
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 1:330 N D ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1522
Mailing Address - Country:US
Mailing Address - Phone:909-888-6602
Mailing Address - Fax:
Practice Address - Street 1:330 N D ST STE 300
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1522
Practice Address - Country:US
Practice Address - Phone:909-888-6602
Practice Address - Fax:909-888-6619
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18846363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0017240Medicaid
CAZZZ96447ZMedicare ID - Type Unspecified
CAA33288Medicare UPIN