Provider Demographics
NPI:1679024426
Name:MARTINEZ, DANIELLE ELISA (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ELISA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13768 ROSWELL AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1402
Mailing Address - Country:US
Mailing Address - Phone:909-364-1617
Mailing Address - Fax:909-364-1126
Practice Address - Street 1:13768 ROSWELL AVE STE 115
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-1402
Practice Address - Country:US
Practice Address - Phone:909-364-1617
Practice Address - Fax:909-364-1126
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55126363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical