Provider Demographics
NPI:1700279510
Name:MARTINEZ, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:F
Other - Last Name:MARTINEZ-MEDINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5901 WHISKEY RIVER DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-4105
Mailing Address - Country:US
Mailing Address - Phone:719-432-9456
Mailing Address - Fax:
Practice Address - Street 1:1259 LAKE PLAZA DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3504
Practice Address - Country:US
Practice Address - Phone:719-333-5804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0174955163W00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse