Healthcare Provider Details

I. General information

NPI: 1841121860
Provider Name (Legal Business Name): GUILLERMO EZEQUIEL MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 W FRANKLIN BLVD
GASTONIA NC
28052-1468
US

IV. Provider business mailing address

PO BOX 746724
ATLANTA GA
30374-6724
US

V. Phone/Fax

Practice location:
  • Phone: 704-396-7143
  • Fax: 980-305-5123
Mailing address:
  • Phone: 833-804-1695
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5025219
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: