Healthcare Provider Details

I. General information

NPI: 1376134155
Provider Name (Legal Business Name): NYLVIA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 W 1ST ST STE G
TUSTIN CA
92780-2939
US

IV. Provider business mailing address

661 W 1ST ST STE G
TUSTIN CA
92780-2939
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-9890
  • Fax: 714-665-9891
Mailing address:
  • Phone: 714-665-9890
  • Fax: 714-665-9891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: