Healthcare Provider Details

I. General information

NPI: 1568186138
Provider Name (Legal Business Name): MARCOS MARTINEZ JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7513
US

IV. Provider business mailing address

4100 OJOS NEGROS DR NW
ALBUQUERQUE NM
87120-4965
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-5565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1644
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: