Healthcare Provider Details

I. General information

NPI: 1427159367
Provider Name (Legal Business Name): SANDRA B MAMPOUYA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21468 WHITEHALL TER
QUEENS VILLAGE NY
11427-1829
US

IV. Provider business mailing address

21468 WHITEHALL TER
QUEENS VILLAGE NY
11427-1829
US

V. Phone/Fax

Practice location:
  • Phone: 718-740-0253
  • Fax:
Mailing address:
  • Phone: 718-740-0253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009842
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: