Healthcare Provider Details

I. General information

NPI: 1366836033
Provider Name (Legal Business Name): KAYLA C MARTINEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLA C MILLER PA-C

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-8818
  • Fax: 309-624-8820
Mailing address:
  • Phone: 309-624-8818
  • Fax: 309-624-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-005185
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: