Provider Demographics
NPI:1407045917
Name:ROBERTS, GRACIE-ANN SAMADH (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:GRACIE-ANN
Middle Name:SAMADH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 PORT RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1714
Mailing Address - Country:US
Mailing Address - Phone:917-830-1235
Mailing Address - Fax:
Practice Address - Street 1:439 PORT RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1714
Practice Address - Country:US
Practice Address - Phone:917-830-1235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-20
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant