Provider Demographics
NPI:1962489658
Name:MARTIN, MARY ANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY ANNE
Other - Middle Name:
Other - Last Name:MARTIN BARRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1462 ERIE BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12305-1026
Mailing Address - Country:US
Mailing Address - Phone:518-243-1500
Mailing Address - Fax:
Practice Address - Street 1:216 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2408
Practice Address - Country:US
Practice Address - Phone:518-243-3300
Practice Address - Fax:518-377-9151
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400240363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4129368OtherMVP
NY000408304001OtherBLUE CROSS
NY11488383OtherCAQH
NY050322000010OtherFIDELIS
NYS40981Medicare UPIN
NY4129368OtherMVP