Provider Demographics
NPI:1962983056
Name:MARTINEZ, MARTIN TYLER (PTA)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:TYLER
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 LAKEPARK DR
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:TX
Mailing Address - Zip Code:76266-1406
Mailing Address - Country:US
Mailing Address - Phone:806-215-4519
Mailing Address - Fax:
Practice Address - Street 1:208 N PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:PILOT POINT
Practice Address - State:TX
Practice Address - Zip Code:76258-4057
Practice Address - Country:US
Practice Address - Phone:940-324-6620
Practice Address - Fax:940-324-6624
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2077941225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant