Provider Demographics
NPI:1487683769
Name:SAM, RANDALL B (ANP)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:B
Last Name:SAM
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 CENTRAL AVE # VD
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:14048-2515
Mailing Address - Country:US
Mailing Address - Phone:716-710-8266
Mailing Address - Fax:
Practice Address - Street 1:520 CENTRAL AVE # VD
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-2515
Practice Address - Country:US
Practice Address - Phone:716-710-8266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303144363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY223765Medicaid
NYP21145Medicare UPIN
NYDD0659Medicare ID - Type Unspecified