Healthcare Provider Details

I. General information

NPI: 1124378989
Provider Name (Legal Business Name): CANDICE JANE MARTINEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CANDICE JANE KOLB

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 N COLLINS BLVD
RICHARDSON TX
75080
US

IV. Provider business mailing address

4471 LONG PRAIRIE RD STE 100
FLOWER MOUND TX
75028-1755
US

V. Phone/Fax

Practice location:
  • Phone: 972-316-4555
  • Fax:
Mailing address:
  • Phone: 972-316-4555
  • Fax: 505-938-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA08639
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: