Provider Demographics
NPI:1881148401
Name:MARTINEZ, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 RAYNOLDS ST # 51015
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1613
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:
Practice Address - Street 1:4815 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2705
Practice Address - Country:US
Practice Address - Phone:915-215-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant