Healthcare Provider Details

I. General information

NPI: 1821989963
Provider Name (Legal Business Name): MARTIN DONJUAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 WEST COLORADO BLVD PAVILLION 2, SUITE 933
DALLAS TX
75028
US

IV. Provider business mailing address

221 W. COLORADO BLVD. PAVILION II SUITE 933
DALLAS TX
75208
US

V. Phone/Fax

Practice location:
  • Phone: 214-947-3684
  • Fax:
Mailing address:
  • Phone: 214-947-3684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19449
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: