Provider Demographics
NPI:1679204747
Name:MARTINOLICH, ALEXANDRA DANIELLE
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:DANIELLE
Last Name:MARTINOLICH
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 1:19 DALE RD
Mailing Address - Street 2:
Mailing Address - City:HALESITE
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1420
Mailing Address - Country:US
Mailing Address - Phone:631-827-7084
Mailing Address - Fax:
Practice Address - Street 1:888 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4914
Practice Address - Country:US
Practice Address - Phone:516-719-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant