Provider Demographics
NPI:1386893030
Name:MONTERO, MARTHA ELISA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:ELISA
Last Name:MONTERO
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 1:1670 EAGLE HARBOR PKWY
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4820
Mailing Address - Country:US
Mailing Address - Phone:904-644-0700
Mailing Address - Fax:
Practice Address - Street 1:1670 EAGLE HARBOR PKWY
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4820
Practice Address - Country:US
Practice Address - Phone:904-644-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9218889363LF0000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010390100Medicaid
GA003159802AMedicaid
FLCK836RMedicare PIN