1356511174 NPI number — MARTHA KATHLEEN PASSINO PNP

Table of content: MARTHA KATHLEEN PASSINO PNP (NPI 1356511174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356511174 NPI number — MARTHA KATHLEEN PASSINO PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PASSINO
Provider First Name:
MARTHA
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORRIGAN
Provider Other First Name:
MARTHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356511174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 CAREY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUEENSBURY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12804-7880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-761-0300
Provider Business Mailing Address Fax Number:
518-824-2388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
87 PLAZA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLATTSBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12901-6438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-536-7060
Provider Business Practice Location Address Fax Number:
518-536-7075
Provider Enumeration Date:
03/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  F381931 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02957404 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".