Provider Demographics
NPI:1013663111
Name:MARTINEZ, JUSTIN ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:A
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6880
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6880
Mailing Address - Country:US
Mailing Address - Phone:505-216-0332
Mailing Address - Fax:505-982-0279
Practice Address - Street 1:4710 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2155
Practice Address - Country:US
Practice Address - Phone:505-955-9454
Practice Address - Fax:505-888-9644
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2022-0121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant