Provider Demographics
NPI:1336738913
Name:MARTENSEN, SHANE THOMAS
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:THOMAS
Last Name:MARTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 THE MOOR
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2922
Mailing Address - Country:US
Mailing Address - Phone:631-383-2476
Mailing Address - Fax:
Practice Address - Street 1:35 THE MOOR
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2922
Practice Address - Country:US
Practice Address - Phone:631-383-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant