Provider Demographics
NPI:1720970833
Name:SAM, PASCAL
Entity type:Individual
Prefix:
First Name:PASCAL
Middle Name:
Last Name:SAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 WYONA ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-3010
Mailing Address - Country:US
Mailing Address - Phone:516-426-8632
Mailing Address - Fax:
Practice Address - Street 1:192 WYONA ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-3010
Practice Address - Country:US
Practice Address - Phone:516-426-8632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver