Provider Demographics
NPI:1225563166
Name:MARTINEZ, LOREN (PA)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 66TH ST
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1734
Mailing Address - Country:US
Mailing Address - Phone:718-639-3603
Mailing Address - Fax:718-639-3605
Practice Address - Street 1:6506 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2928
Practice Address - Country:US
Practice Address - Phone:718-639-3603
Practice Address - Fax:718-639-3605
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05593980Medicaid