Provider Demographics
NPI:1265572424
Name:MARTINEZ, EMANUEL (PA)
Entity type:Individual
Prefix:
First Name:EMANUEL
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1634
Mailing Address - Country:US
Mailing Address - Phone:646-258-9463
Mailing Address - Fax:
Practice Address - Street 1:104 COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-1634
Practice Address - Country:US
Practice Address - Phone:646-258-9463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011093-1363A00000X
NJ25MP00510800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant