Basic Information
| Provider Information | |||||||||
| NPI: | 1568839801 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | PATRICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19472 US ROUTE 11 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136015387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157823941 | ||||||||
| FaxNumber: | 3157823816 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 COUNTY ROUTE 64 | ||||||||
| Address2: | |||||||||
| City: | MEXICO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131143229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159635421 | ||||||||
| FaxNumber: | 3159637693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2015 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 039103 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.