Provider Demographics
NPI:1487256814
Name:SAMUEL, NISSY SAJI (PA-C)
Entity type:Individual
Prefix:MISS
First Name:NISSY
Middle Name:SAJI
Last Name:SAMUEL
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 1:25602 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1618
Mailing Address - Country:US
Mailing Address - Phone:718-343-3535
Mailing Address - Fax:
Practice Address - Street 1:25602 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1618
Practice Address - Country:US
Practice Address - Phone:718-343-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant