Provider Demographics
NPI:1679115265
Name:MARTIN, PATRICIA PEREZ
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:PEREZ
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 NW HAWTHORNE AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-3417
Mailing Address - Country:US
Mailing Address - Phone:541-471-3842
Mailing Address - Fax:
Practice Address - Street 1:550 NE E ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2326
Practice Address - Country:US
Practice Address - Phone:541-955-5186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator