Healthcare Provider Details

I. General information

NPI: 1114230117
Provider Name (Legal Business Name): JUAN EDWARDO MARTINEZ CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2010
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 BRIARGATE PKWY
COLORADO SPRINGS CO
80920-7835
US

IV. Provider business mailing address

6478 GOLDEN BRIAR LN
COLORADO SPRINGS CO
80927-4195
US

V. Phone/Fax

Practice location:
  • Phone: 832-444-1660
  • Fax:
Mailing address:
  • Phone: 832-444-1660
  • Fax: 888-972-4762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: