Healthcare Provider Details

I. General information

NPI: 1992007280
Provider Name (Legal Business Name): ENID B MARTINEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12580 UNIVERSITY DR SUITE 200
FORT MYERS FL
33907-5686
US

IV. Provider business mailing address

12580 UNIVERSITY DR SUITE 200
FORT MYERS FL
33907-5686
US

V. Phone/Fax

Practice location:
  • Phone: 239-274-0005
  • Fax: 239-278-4718
Mailing address:
  • Phone: 239-274-0005
  • Fax: 239-278-4718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: