Healthcare Provider Details

I. General information

NPI: 1689347569
Provider Name (Legal Business Name): MADISON LEE MARTINO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PARAGON WAY STE 300
FREEHOLD NJ
07728-7805
US

IV. Provider business mailing address

2701 QUEENS PLZ N FL 10
LONG ISLAND CITY NY
11101-4022
US

V. Phone/Fax

Practice location:
  • Phone: 732-462-9800
  • Fax:
Mailing address:
  • Phone: 201-310-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00633700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: