Healthcare Provider Details

I. General information

NPI: 1215313069
Provider Name (Legal Business Name): MAYRA O MARTINEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAYRA OFELIA MARTINEZ PA

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2768 PHARMACY RD
RIO GRANDE CITY TX
78582-6201
US

IV. Provider business mailing address

PO BOX 117
ROMA TX
78584-0117
US

V. Phone/Fax

Practice location:
  • Phone: 956-487-5621
  • Fax: 956-487-5862
Mailing address:
  • Phone: 956-607-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09800
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: