Healthcare Provider Details

I. General information

NPI: 1376853879
Provider Name (Legal Business Name): MARTINA NANKIVELL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 09/23/2023
Certification Date: 09/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 PINE AVE STE 609
LONG BEACH CA
90802-2310
US

IV. Provider business mailing address

320 PINE AVE STE 609
LONG BEACH CA
90802-2310
US

V. Phone/Fax

Practice location:
  • Phone: 562-279-0180
  • Fax:
Mailing address:
  • Phone: 562-279-0180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12836
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7436
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2247
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116057
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21291
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: