Provider Demographics
NPI:1548417801
Name:ANSARY, MIR SAMIM AHMAD (PA-C)
Entity Type:Individual
Prefix:
First Name:MIR SAMIM
Middle Name:AHMAD
Last Name:ANSARY
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2081 BRONZE STAR DR
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95776-5423
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-661-1067
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant