Healthcare Provider Details

I. General information

NPI: 1932537354
Provider Name (Legal Business Name): JON MARTINSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD SUITE I - 164
GLENDALE AZ
85306-3709
US

IV. Provider business mailing address

6233 W BEHREND DR APT 2055
GLENDALE AZ
85308-6929
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2100
  • Fax: 623-776-9419
Mailing address:
  • Phone: 623-878-2100
  • Fax: 623-776-9419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5512
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: