Healthcare Provider Details

I. General information

NPI: 1891904132
Provider Name (Legal Business Name): MARIO P MARTINEZ NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 12TH AVE RD
NAMPA ID
83686-5738
US

IV. Provider business mailing address

10482 W CARLTON BAY DR
GARDEN CITY ID
83714-5143
US

V. Phone/Fax

Practice location:
  • Phone: 208-498-1080
  • Fax:
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-817A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: