Healthcare Provider Details

I. General information

NPI: 1922506294
Provider Name (Legal Business Name): SAMIUL J ISLAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 MENAUL BLVD NE STE B
ALBUQUERQUE NM
87107-1872
US

IV. Provider business mailing address

3101 MENAUL BLVD NE STE B
ALBUQUERQUE NM
87107-1872
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-5151
  • Fax:
Mailing address:
  • Phone: 505-842-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0027
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: