Provider Demographics
NPI:1104248830
Name:MARTINEZ, PRISCILA
Entity type:Individual
Prefix:
First Name:PRISCILA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 N COIT RD STE 3040
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5418
Mailing Address - Country:US
Mailing Address - Phone:972-238-8092
Mailing Address - Fax:972-238-8093
Practice Address - Street 1:970 N COIT RD STE 3040
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5418
Practice Address - Country:US
Practice Address - Phone:972-238-8092
Practice Address - Fax:972-238-8093
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX337815YKQLMedicare PIN