Provider Demographics
NPI:1720061716
Name:MARTINEZ, ELISA R (PA)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:R
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:R
Other - Last Name:KONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:2101 TENAYA DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-3930
Practice Address - Country:US
Practice Address - Phone:209-576-6766
Practice Address - Fax:209-576-6776
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12678363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA126780Medicare ID - Type Unspecified
CAS54159Medicare UPIN