Healthcare Provider Details

I. General information

NPI: 1497122337
Provider Name (Legal Business Name): SAMEERA FORHAN AWWAL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

5645 MAIN ST
FLUSHING NY
11355-5045
US

V. Phone/Fax

Practice location:
  • Phone: 186-667-0682
  • Fax: 718-533-1770
Mailing address:
  • Phone: 866-670-6824
  • Fax: 718-533-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number018985
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: