Provider Demographics
NPI:1255844197
Name:MARTIN, PHILEASE J
Entity Type:Individual
Prefix:
First Name:PHILEASE
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21715 JAMAICA AVE APT 2B
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-2122
Mailing Address - Country:US
Mailing Address - Phone:773-910-2518
Mailing Address - Fax:
Practice Address - Street 1:2001 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-4501
Practice Address - Country:US
Practice Address - Phone:203-658-8291
Practice Address - Fax:203-658-8294
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021588-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical