Basic Information
| Provider Information | |||||||||
| NPI: | 1205113040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | PETER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | SAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117822808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166226000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1145 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316653376 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2011 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 015323 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.