Provider Demographics
NPI:1124018239
Name:MARTIN, CAROL ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:CAROL ANN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:21 ORBIT DR
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3015
Mailing Address - Country:US
Mailing Address - Phone:631-751-3752
Mailing Address - Fax:
Practice Address - Street 1:3 TECHNOLOGY DR
Practice Address - Street 2:SUITE 700
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4064
Practice Address - Country:US
Practice Address - Phone:631-444-5220
Practice Address - Fax:631-444-5225
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302776-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02377728Medicaid
NY02377728Medicaid
NYP02739Medicare UPIN