Provider Demographics
NPI:1679809180
Name:MARTINEZ CARDENAS, VICENTE MANUEL (PNP-BC, ARNP)
Entity type:Individual
Prefix:
First Name:VICENTE
Middle Name:MANUEL
Last Name:MARTINEZ CARDENAS
Suffix:
Gender:M
Credentials:PNP-BC, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 W DUVAL ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-3811
Mailing Address - Country:US
Mailing Address - Phone:386-755-1546
Mailing Address - Fax:386-755-2283
Practice Address - Street 1:1002 11TH ST SW
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-3606
Practice Address - Country:US
Practice Address - Phone:386-364-8050
Practice Address - Fax:386-364-7068
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9247766363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics