Provider Demographics
NPI:1497460174
Name:AUBOURG, MARTHA (NP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:AUBOURG
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 1:318 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-6316
Mailing Address - Country:US
Mailing Address - Phone:516-439-8145
Mailing Address - Fax:
Practice Address - Street 1:600 COMMUNITY DR STE 304
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3818
Practice Address - Country:US
Practice Address - Phone:516-439-8145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF348026-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily