Provider Demographics
NPI:1336394550
Name:MARTINO, NICOLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:MARTINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:DORCHINSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1 FEDERAL ST # 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:900 CENTENNIAL BLVD STE 203
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4637
Practice Address - Country:US
Practice Address - Phone:856-325-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053481363AM0700X
NJ25MP00384500363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232664784OtherTIN