Healthcare Provider Details

I. General information

NPI: 1396398947
Provider Name (Legal Business Name): MARTINEZ ANTUAN COATES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 PALM ST BLD T APT147
LAS VEGAS NV
89104
UM

IV. Provider business mailing address

1755 PALM ST
LAS VEGAS NV
89104-4700
US

V. Phone/Fax

Practice location:
  • Phone: 702-808-1846
  • Fax:
Mailing address:
  • Phone: 702-808-1846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number2600245340
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: