Healthcare Provider Details

I. General information

NPI: 1700279510
Provider Name (Legal Business Name): JUAN MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUAN F MARTINEZ-MEDINA

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 LAKE PLAZA DR
COLORADO SPRINGS CO
80906-3504
US

IV. Provider business mailing address

5901 WHISKEY RIVER DR
COLORADO SPRINGS CO
80923-4105
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5804
  • Fax:
Mailing address:
  • Phone: 719-432-9456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0174955
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0174955
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: