Basic Information
| Provider Information | |||||||||
| NPI: | 1659389096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTE | ||||||||
| FirstName: | JIM | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 EAST 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662282236 | ||||||||
| FaxNumber: | 7607373430 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 EAST 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662282236 | ||||||||
| FaxNumber: | 7607373430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA17165 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | WPA17165 | 01 | CA | PTAN | OTHER |