Provider Demographics
NPI:1508229311
Name:MARTINEZ, LAURA XIMENA (INTERN STUDENT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:XIMENA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:INTERN STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 WATERFORD RD
Mailing Address - Street 2:
Mailing Address - City:ISLAND PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11558-1144
Mailing Address - Country:US
Mailing Address - Phone:516-474-8056
Mailing Address - Fax:
Practice Address - Street 1:488 BEACH 66TH ST
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1430
Practice Address - Country:US
Practice Address - Phone:718-634-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program