Healthcare Provider Details

I. General information

NPI: 1619654118
Provider Name (Legal Business Name): WADANA SAMAAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 09/28/2026
Certification Date: 06/28/2023
Deactivation Date: 02/02/2024
Reactivation Date: 04/15/2024

III. Provider practice location address

725 EAST ADAMS ST 5TH FL B&C
SYRACUSE NY
13210
US

IV. Provider business mailing address

725 EAST ADAMS ST 5TH FL B&C
SYRACUSE NY
13210
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5726
  • Fax: 315-464-2510
Mailing address:
  • Phone: 315-464-5726
  • Fax: 315-464-2510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number347616
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: