Basic Information
| Provider Information | |||||||||
| NPI: | 1114230117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | EDWARDO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6478 GOLDEN BRIAR LN | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809274195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324441660 | ||||||||
| FaxNumber: | 8889724762 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 BRIARGATE PKWY | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324441660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2010 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.