Provider Demographics
NPI:1598866444
Name:SAM, LUMANIE (PA)
Entity Type:Individual
Prefix:MS
First Name:LUMANIE
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79-01 BROADWAY
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-1921
Mailing Address - Fax:718-334-3432
Practice Address - Street 1:82-68 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-3225
Practice Address - Fax:718-883-6193
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid