Provider Demographics
NPI:1821484213
Name:SALISU, MARIAM BUKKY (MD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:BUKKY
Last Name:SALISU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:570-326-8723
Mailing Address - Fax:570-326-8922
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1900
Practice Address - Country:US
Practice Address - Phone:570-326-8457
Practice Address - Fax:570-326-7989
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD471881207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine