Healthcare Provider Details

I. General information

NPI: 1013663111
Provider Name (Legal Business Name): JUSTIN ANTHONY MARTINEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUSTIN A MARTINEZ

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 ENCINO PL NE STE 12
ALBUQUERQUE NM
87102-2638
US

IV. Provider business mailing address

101 HOSPITAL LOOP NE STE 209
ALBUQUERQUE NM
87109-2128
US

V. Phone/Fax

Practice location:
  • Phone: 866-606-3867
  • Fax:
Mailing address:
  • Phone: 505-848-3773
  • Fax: 505-848-3741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0009075
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0121
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: