Provider Demographics
NPI:1689347569
Name:MARTINO, MADISON LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:LEE
Last Name:MARTINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 QUEENS PLZ N FL 10
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-4022
Mailing Address - Country:US
Mailing Address - Phone:201-310-4999
Mailing Address - Fax:
Practice Address - Street 1:4 PARAGON WAY STE 300
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-7805
Practice Address - Country:US
Practice Address - Phone:732-462-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00633700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant