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Individual
MARTIN SAMPLE
Active
Individual
MARTIN SAMPLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
010377
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000413205001
BSNENY
—
05
—
03875261
—
NY
01
—
070808000134
FIDELIS
NY
01
—
110126992
CDPHP
—
01
—
3013540
MVP
—
Enumeration date
04/02/2007
Last updated
07/22/2015
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