Basic Information
| Provider Information | |||||||||
| NPI: | 1558785626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | ELEA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26028 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627215 | ||||||||
| FaxNumber: | 5052321627 | ||||||||
| Practice Location | |||||||||
| Address1: | 10511 GOLF COURSE RD NW STE 204 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871145917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052321100 | ||||||||
| FaxNumber: | 5052321121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2014 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CNP-02490 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 42578361 | 05 | NM | MEDICAID |