Provider Demographics
NPI:1891904132
Name:MARTINEZ, MARIO P (NP)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:P
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1075 S CURTIS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1350
Practice Address - Country:US
Practice Address - Phone:208-367-8333
Practice Address - Fax:208-367-2003
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP817A363L00000X
IDNP-817A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80705880Medicaid
ID807746300Medicaid
ID807746300Medicaid
P00427857Medicare PIN