Healthcare Provider Details

I. General information

NPI: 1033255922
Provider Name (Legal Business Name): WILFREDO MARTINEZ P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 ARLINGTON AVE
RIVERSIDE CA
92504-2505
US

IV. Provider business mailing address

6291 ACELA CT
RIVERSIDE CA
92506-3787
US

V. Phone/Fax

Practice location:
  • Phone: 951-689-2955
  • Fax: 951-689-2477
Mailing address:
  • Phone: 951-273-1188
  • Fax: 951-346-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13532
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: