1033757711 NPI number — BRANDON REY MARTINEZ MSN, PMHNP-BC, APRN

Table of content: BRANDON REY MARTINEZ MSN, PMHNP-BC, APRN (NPI 1033757711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033757711 NPI number — BRANDON REY MARTINEZ MSN, PMHNP-BC, APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEZ
Provider First Name:
BRANDON
Provider Middle Name:
REY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, PMHNP-BC, APRN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033757711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6545 TIMBER POINT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89148-4297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-526-7610
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2120 ALPINE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91901-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-526-7610
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  95022290 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X , with the licence number: 825008 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CS29727 . This is a "NEVADA BOARD OF PHARMACY" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 825008 . This is a "NEVADA APRN LICENSE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 95022290 . This is a "CALIFORNIA NURSE PRACTITIONER AND NURSE PRACTITIONER FURNISHING/PRESCRIBING LIC." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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