Provider Demographics
NPI:1720233042
Name:MARTINEZ, EDWARD A (PA)
Entity Type:Individual
Prefix:
First Name:EDWARD
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 1:1212 N HIGHWAY 377
Mailing Address - Street 2:SUITE 119
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-6916
Mailing Address - Country:US
Mailing Address - Phone:682-831-1591
Mailing Address - Fax:682-831-1598
Practice Address - Street 1:1212 N HIGHWAY 377
Practice Address - Street 2:SUITE 119
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-6916
Practice Address - Country:US
Practice Address - Phone:682-831-1591
Practice Address - Fax:682-831-1598
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04174363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04174OtherSTATE LICENSE NUMBER
TXPA04174OtherSTATE LICENSE NUMBER