Healthcare Provider Details

I. General information

NPI: 1396219655
Provider Name (Legal Business Name): RYAN ANTHONY MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 01/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 LOWER CAMPUS RD
HONOLULU HI
96822-2352
US

IV. Provider business mailing address

20264 JUNE CT
RIVERSIDE CA
92508-2939
US

V. Phone/Fax

Practice location:
  • Phone: 808-956-4637
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: