Provider Demographics
NPI:1750491908
Name:MARTINEZ, JONATHAN (PAC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4959 PALO VERDE ST
Mailing Address - Street 2:STE 101A
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2340
Mailing Address - Country:US
Mailing Address - Phone:909-621-2562
Mailing Address - Fax:909-621-2480
Practice Address - Street 1:4959 PALO VERDE ST
Practice Address - Street 2:STE 101A
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2340
Practice Address - Country:US
Practice Address - Phone:909-621-2562
Practice Address - Fax:909-621-2480
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 13140363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical