Provider Demographics
NPI:1588017164
Name:RAZA, MUBUSHAR IKRAM
Entity type:Individual
Prefix:
First Name:MUBUSHAR
Middle Name:IKRAM
Last Name:RAZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2407
Mailing Address - Country:US
Mailing Address - Phone:631-983-3273
Mailing Address - Fax:
Practice Address - Street 1:1757 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-2407
Practice Address - Country:US
Practice Address - Phone:631-983-3237
Practice Address - Fax:631-961-8775
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307814363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY307814Other307814