Provider Demographics
NPI:1518058130
Name:ISLAM, MD AMINUL (PA-C)
Entity Type:Individual
Prefix:
First Name:MD
Middle Name:AMINUL
Last Name:ISLAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 THE MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:CENTRE HALL
Mailing Address - State:PA
Mailing Address - Zip Code:16828-9231
Mailing Address - Country:US
Mailing Address - Phone:814-364-2161
Mailing Address - Fax:814-364-9448
Practice Address - Street 1:132 THE MEADOWS DR
Practice Address - Street 2:
Practice Address - City:CENTRE HALL
Practice Address - State:PA
Practice Address - Zip Code:16828-9231
Practice Address - Country:US
Practice Address - Phone:814-364-2161
Practice Address - Fax:814-364-9448
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA333363A00000X
PAMA055870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0TH000Medicare UPIN