Provider Demographics
NPI:1083168520
Name:SHUKUR, MMA (RN,SA-C)
Entity Type:Individual
Prefix:
First Name:MMA
Middle Name:
Last Name:SHUKUR
Suffix:
Gender:M
Credentials:RN,SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 MERRICK BLVD APT 9D
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4105
Mailing Address - Country:US
Mailing Address - Phone:347-848-6004
Mailing Address - Fax:
Practice Address - Street 1:9111 218TH ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428
Practice Address - Country:US
Practice Address - Phone:347-848-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-13
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY749721163W00000X
246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant