Provider Demographics
NPI:1013038975
Name:SAMPLE, MARTIN (PA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MCCLELLAN ST
Mailing Address - Street 2:2 WEST
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 NOTT ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2425
Practice Address - Country:US
Practice Address - Phone:518-243-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010377363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
3013540OtherMVP
000413205001OtherBSNENY
NY070808000134OtherFIDELIS
NY03875261Medicaid
110126992OtherCDPHP
NY03875261Medicaid