Provider Demographics
NPI:1093118457
Name:MARTIN, MARIAN L (NP)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 FATHER CAPODANNO BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4242
Mailing Address - Country:US
Mailing Address - Phone:718-982-9001
Mailing Address - Fax:718-982-9008
Practice Address - Street 1:2066 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3916
Practice Address - Country:US
Practice Address - Phone:718-982-9001
Practice Address - Fax:718-982-9008
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334088-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily