MEDICARE: MR. JEREMY ANGELO MARTINEZ FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R49706	NM

General Provider Information

NPI Number	:	1730331976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMY ANGELO MARTINEZ FNP

Provider Business Mailing Address
First Line	:	STATE ROAD 571 BLDG 28
Second Line	:
City	:	EL RITO
State	:	NM
Zip	:	87530-0237
Country	:	US
Telephone Number	:	575-581-4728
Fax Number	:	575-581-4731

Provider Business Practice Location Address
First Line	:	STATE ROAD 571 BLDG 28
Second Line	:
City	:	EL RITO
State	:	NM
Zip	:	87530-0237
Country	:	US
Telephone Number	:	575-581-4728
Fax Number	:	575-581-4731

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	02/15/2013

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