Provider Demographics
NPI:1891764106
Name:MARTINEZ, MONIKA RAE (PTA)
Entity Type:Individual
Prefix:
First Name:MONIKA
Middle Name:RAE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313-0358
Mailing Address - Country:US
Mailing Address - Phone:505-786-5291
Mailing Address - Fax:505-786-6440
Practice Address - Street 1:HWY 371 ROUTE 9 JCT
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87311
Practice Address - Country:US
Practice Address - Phone:505-786-5291
Practice Address - Fax:505-786-6440
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant