Provider Demographics
NPI:1003597469
Name:MENDOUNE, SAM TARIK I (NP)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:TARIK
Last Name:MENDOUNE
Suffix:I
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MARC DR
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2139
Mailing Address - Country:US
Mailing Address - Phone:631-335-1657
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-335-1657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311288363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health