Healthcare Provider Details

I. General information

NPI: 1750893756
Provider Name (Legal Business Name): EDWARD MARTINEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 W PARKER RD STE 470
PLANO TX
75093-8338
US

IV. Provider business mailing address

6020 W PARKER RD STE 470
PLANO TX
75093-8338
US

V. Phone/Fax

Practice location:
  • Phone: 972-608-8868
  • Fax: 972-608-0366
Mailing address:
  • Phone: 972-608-8868
  • Fax: 972-608-0366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA11738
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: