Provider Demographics
NPI:1760498547
Name:LEROY, MARTHA (RPAC)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:LEROY
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 WASHINGTON AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1375 WASHINGTON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206
Practice Address - Country:US
Practice Address - Phone:518-482-0007
Practice Address - Fax:518-482-0008
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00777731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC6332Medicare ID - Type Unspecified
P33398Medicare UPIN