MEDICARE: ANSU SAM

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	363LF0000X	Family Nurse Practitioner	346024	NY

General Provider Information

NPI Number	:	1093320251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANSU SAM

Provider Business Mailing Address
First Line	:	2379 WEBSTER ST
Second Line	:
City	:	NORTH BELLMORE
State	:	NY
Zip	:	11710-2124
Country	:	US
Telephone Number	:	516-728-4129
Fax Number	:

Provider Business Practice Location Address
First Line	:	2379 WEBSTER ST
Second Line	:
City	:	NORTH BELLMORE
State	:	NY
Zip	:	11710-2124
Country	:	US
Telephone Number	:	516-728-4129
Fax Number	:

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

Provider Enumeration Date	:	09/14/2020
Last Update Date	:	09/14/2020

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Directions to “ ANSU SAM ” Practice Location

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