Basic Information
| Provider Information | |||||||||
| NPI: | 1891904132 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 EAST GOLDSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836421026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083675170 | ||||||||
| FaxNumber: | 2083675180 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 S CURTIS RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083678333 | ||||||||
| FaxNumber: | 2083672003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 11/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP817A | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | NP-817A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 80705880 | 05 | ID | MEDICAID | 807746300 | 05 | ID | MEDICAID |