Basic Information
| Provider Information | |||||||||
| NPI: | 1821303272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLER | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13460 N 94TH DRIVE | ||||||||
| Address2: | SUITE J1 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13460 N 94TH DRIVE | ||||||||
| Address2: | SUITE J-1 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2010 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 8748 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 555995 | 05 | AZ | MEDICAID |