Provider Demographics
NPI:1255080669
Name:MARTINEZ CHAN, MAYRA
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:MARTINEZ CHAN
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 1:3623 201ST ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1115
Mailing Address - Country:US
Mailing Address - Phone:347-754-8365
Mailing Address - Fax:
Practice Address - Street 1:16216 UNION TPKE STE 303
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1960
Practice Address - Country:US
Practice Address - Phone:718-264-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator