Healthcare Provider Details

I. General information

NPI: 1902811771
Provider Name (Legal Business Name): SELINA ANN MARTIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3016 LONGTOWN COMMONS DR STE 200
COLUMBIA SC
29229-7863
US

IV. Provider business mailing address

900 FRANKLIN AVE
VALLEY STREAM NY
11580-2145
US

V. Phone/Fax

Practice location:
  • Phone: 803-314-9640
  • Fax: 803-314-9641
Mailing address:
  • Phone: 516-719-5758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number017430-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00126700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4969
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: