Provider Demographics
NPI:1306895370
Name:WISA, SHOUKRI MINA (MD)
Entity type:Individual
Prefix:
First Name:SHOUKRI
Middle Name:MINA
Last Name:WISA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-2113
Mailing Address - Country:US
Mailing Address - Phone:585-343-6363
Mailing Address - Fax:585-343-1986
Practice Address - Street 1:164 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-2113
Practice Address - Country:US
Practice Address - Phone:585-343-6363
Practice Address - Fax:585-343-1986
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1705271207R00000X
NY170527207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01127086Medicaid
NYDD2209Medicare PIN
NYE15548Medicare UPIN