Provider Demographics
NPI:1184814071
Name:MARTINEZ, JENNIFER A (PA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:A
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 SW 104 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156
Mailing Address - Country:US
Mailing Address - Phone:305-279-7546
Mailing Address - Fax:305-279-4180
Practice Address - Street 1:7700 SW 104 ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156
Practice Address - Country:US
Practice Address - Phone:305-279-7546
Practice Address - Fax:305-279-4180
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104126207NI0002X
FLPAT9104126363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA 9104126OtherLICENSE
FLAK917ZMedicare UPIN