Provider Demographics
NPI:1568560472
Name:MARTINEZ, JACEN A (PA)
Entity Type:Individual
Prefix:
First Name:JACEN
Middle Name:A
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 1:1400 FRONT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5300
Mailing Address - Country:US
Mailing Address - Phone:410-296-6232
Mailing Address - Fax:410-821-5943
Practice Address - Street 1:1400 FRONT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-5300
Practice Address - Country:US
Practice Address - Phone:410-296-6232
Practice Address - Fax:410-821-5943
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KK0558SSMedicare PIN
MDP20227Medicare UPIN