Provider Demographics
NPI:1417292285
Name:AMIN, KWAME (PA)
Entity Type:Individual
Prefix:
First Name:KWAME
Middle Name:
Last Name:AMIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10748 123RD ST FL 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2924
Mailing Address - Country:US
Mailing Address - Phone:917-609-9754
Mailing Address - Fax:
Practice Address - Street 1:2510 30TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2448
Practice Address - Country:US
Practice Address - Phone:718-932-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016224363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA66577RMedicaid