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NPI Code Detail

MEDICARE: GRACIE-ANN SAMADH ROBERTS PHYSICIAN ASSISTANT

MEDICARE: GRACIE-ANN SAMADH ROBERTS PHYSICIAN ASSISTANT
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
1363A00000XPhysician Assistant011794NY

General Provider Information

NPI Number : 1407045917
Entity Type Code : Individual
Provider Name (Legal Business Name) : GRACIE-ANN SAMADH ROBERTS PHYSICIAN ASSISTANT
Provider Business Mailing Address
First Line : 439 PORT RICHMOND AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10302-1714
Country : US
Telephone Number : 917-830-1235
Fax Number :
Provider Business Practice Location Address
First Line : 439 PORT RICHMOND AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10302-1714
Country : US
Telephone Number : 917-830-1235
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/20/2007
Last Update Date : 08/11/2016

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