Provider Demographics
NPI:1013663111
Name:MARTINEZ, JUSTIN ANTHONY (PA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:MARTINEZ
Suffix:
Gender:
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 1:101 HOSPITAL LOOP NE STE 209
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2128
Mailing Address - Country:US
Mailing Address - Phone:505-848-3773
Mailing Address - Fax:505-848-3741
Practice Address - Street 1:717 ENCINO PL NE STE 12
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2638
Practice Address - Country:US
Practice Address - Phone:866-606-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0009075363A00000X
NMPA2022-0121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant