Provider Demographics
NPI:1780208629
Name:MARTINEZ, IVAN (RN)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 N OLA AVE UNIT 718
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-2026
Mailing Address - Country:US
Mailing Address - Phone:813-404-8922
Mailing Address - Fax:
Practice Address - Street 1:2108 N OLA AVE UNIT 718
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-2026
Practice Address - Country:US
Practice Address - Phone:813-404-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-06
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9381202163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9381202OtherSTATE NURSING LICENSE