Basic Information
| Provider Information | |||||||||
| NPI: | 1336700301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 ROMANO AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331347242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059516493 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056895511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2019 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 9368726 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.