MEDICARE: NIDHA AZAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	020840-1	NY

General Provider Information

NPI Number	:	1942730296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIDHA AZAM

Provider Business Mailing Address
First Line	:	880 WOODMERE DR
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-2736
Country	:	US
Telephone Number	:	347-794-3385
Fax Number	:

Provider Business Practice Location Address
First Line	:	880 WOODMERE DR
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-2736
Country	:	US
Telephone Number	:	347-794-3385
Fax Number	:	347-794-3385

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	06/19/2017

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Directions to “ NIDHA AZAM ” Practice Location

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