Provider Demographics
NPI:1902811771
Name:MARTIN, SELINA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:SELINA
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2145
Mailing Address - Country:US
Mailing Address - Phone:516-719-5758
Mailing Address - Fax:
Practice Address - Street 1:3016 LONGTOWN COMMONS DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7863
Practice Address - Country:US
Practice Address - Phone:803-314-9640
Practice Address - Fax:803-314-9641
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4969363A00000X
NJ25MP00126700363A00000X
NY017430-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ086395ACDMedicare ID - Type Unspecified
NJQ03883Medicare UPIN