Basic Information
| Provider Information | |||||||||
| NPI: | 1124018239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | CAROL ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 ORBIT DR | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117903015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513752 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 TECHNOLOGY DR | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117334064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314445220 | ||||||||
| FaxNumber: | 6314445225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F302776-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 02377728 | 05 | NY | MEDICAID |