Basic Information
| Provider Information | |||||||||
| NPI: | 1629347349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | MAKRISTINA | ||||||||
| MiddleName: | ATENCIO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTINEZ | ||||||||
| OtherFirstName: | MA.KRISTINA | ||||||||
| OtherMiddleName: | ATENCIO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1244 FORT WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190341743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156466504 | ||||||||
| FaxNumber: | 2156466546 | ||||||||
| Practice Location | |||||||||
| Address1: | 1244 FORT WASHINGTON AVE STE N1 | ||||||||
| Address2: | |||||||||
| City: | FORT WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190341743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156466504 | ||||||||
| FaxNumber: | 2156466546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2011 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | SPO11863 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.