Healthcare Provider Details

I. General information

NPI: 1275681306
Provider Name (Legal Business Name): ELIZABETH ANNE MARTINEZ P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WEIMER RD
TAOS NM
87571-6346
US

IV. Provider business mailing address

PO BOX 670
RANCHOS DE TAOS NM
87557-0670
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-2073
  • Fax: 505-751-3031
Mailing address:
  • Phone: 505-758-1970
  • Fax: 505-751-3031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number78-PA006
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: