MEDICARE: EDWARD A MARTINEZ PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA04174	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA04174	OTHER	TX	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1720233042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD A MARTINEZ PA

Provider Business Mailing Address
First Line	:	1212 N HIGHWAY 377
Second Line	:	SUITE 119
City	:	ROANOKE
State	:	TX
Zip	:	76262-6916
Country	:	US
Telephone Number	:	682-831-1591
Fax Number	:	682-831-1598

Provider Business Practice Location Address
First Line	:	1212 N HIGHWAY 377
Second Line	:	SUITE 119
City	:	ROANOKE
State	:	TX
Zip	:	76262-6916
Country	:	US
Telephone Number	:	682-831-1591
Fax Number	:	682-831-1598

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2008
Last Update Date	:	06/10/2013

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Directions to “ EDWARD A MARTINEZ PA” Practice Location

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