Provider Demographics
NPI:1912210238
Name:MARTHEDAL, ERIN ELISABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:ELISABETH
Last Name:MARTHEDAL
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 1:47 MERCER ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-5530
Mailing Address - Country:US
Mailing Address - Phone:559-940-2606
Mailing Address - Fax:
Practice Address - Street 1:1 ROBERT WOOD JOHNSON PL
Practice Address - Street 2:MEB 104
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1928
Practice Address - Country:US
Practice Address - Phone:732-235-8717
Practice Address - Fax:732-235-7379
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00238300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00981583OtherRR MCR
NJ189942UA1Medicare PIN