Provider Demographics
NPI:1487610663
Name:MARTINEZ, JEFFREY L (PA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 BROADCASTING RD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3203
Mailing Address - Country:US
Mailing Address - Phone:610-372-1140
Mailing Address - Fax:610-372-7684
Practice Address - Street 1:1270 BROADCASTING RD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3203
Practice Address - Country:US
Practice Address - Phone:610-372-1140
Practice Address - Fax:610-372-7684
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003079L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50046110OtherCAPITAL BC
PA087143RMXMedicare ID - Type Unspecified
PA50046110OtherCAPITAL BC