Provider Demographics
NPI:1982790762
Name:DEMARTINI, DANIEL M (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:M
Last Name:DEMARTINI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 FLY ROAD
Mailing Address - Street 2:STE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13015
Mailing Address - Country:US
Mailing Address - Phone:315-464-4472
Mailing Address - Fax:315-464-5223
Practice Address - Street 1:6620 FLY RD
Practice Address - Street 2:STE 200
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9717
Practice Address - Country:US
Practice Address - Phone:315-464-4472
Practice Address - Fax:315-464-5223
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009617363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ05951Medicare UPIN
NYQ05951Medicare UPIN