=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497542310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN ANDRE MARTINEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2025
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3016 W CHARLESTON BLVD STE 150
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-1964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 725-259-6163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 96881
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89193-6881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 725-259-6163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number | CHW2-5132
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------