Basic Information
| Provider Information | |||||||||
| NPI: | 1619976933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | TERI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 ROE AVE | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149051629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077374508 | ||||||||
| FaxNumber: | 6077355738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/20/2006 | ||||||||
| NPIReactivationDate: | 03/27/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F330978-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 330978 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02093850 | 05 | NY | MEDICAID |