Provider Demographics
NPI:1689719304
Name:PACO, MARTINA HERNANDEZ (PT)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:HERNANDEZ
Last Name:PACO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:PACO
Other - Last Name:FLORES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:3017 MELBOURNE CT E
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-7540
Mailing Address - Country:US
Mailing Address - Phone:615-232-9201
Mailing Address - Fax:615-232-9202
Practice Address - Street 1:4982 LEBANON PIKE
Practice Address - Street 2:SUITE C
Practice Address - City:OLD HICKORY
Practice Address - State:TN
Practice Address - Zip Code:37138-4107
Practice Address - Country:US
Practice Address - Phone:615-232-9201
Practice Address - Fax:615-232-9202
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3648498Medicaid
TN4100643OtherBILLING NUMBER
TN4100643OtherBILLING NUMBER