Provider Demographics
NPI:1528720083
Name:MARTIN, ANDRIA MICHELLE
Entity type:Individual
Prefix:
First Name:ANDRIA
Middle Name:MICHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SUBURBAN PARK DR APT 1
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-1956
Mailing Address - Country:US
Mailing Address - Phone:315-720-3456
Mailing Address - Fax:
Practice Address - Street 1:709 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1669
Practice Address - Country:US
Practice Address - Phone:315-937-5954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist