Provider Demographics
NPI:1174367312
Name:MARTINEZ, LA TISHA (NP)
Entity type:Individual
Prefix:
First Name:LA TISHA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5900 CANYON VISTA DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6621
Mailing Address - Country:US
Mailing Address - Phone:505-400-0693
Mailing Address - Fax:
Practice Address - Street 1:3825 EUBANK BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3590
Practice Address - Country:US
Practice Address - Phone:052-928-5755
Practice Address - Fax:505-292-8409
Is Sole Proprietor?:No
Enumeration Date:2024-06-22
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM79563363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner