Provider Demographics
NPI:1922506294
Name:ISLAM, SAMIUL J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SAMIUL
Middle Name:J
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 1:3101 MENAUL BLVD NE STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1872
Mailing Address - Country:US
Mailing Address - Phone:505-842-5151
Mailing Address - Fax:
Practice Address - Street 1:3101 MENAUL BLVD NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1872
Practice Address - Country:US
Practice Address - Phone:505-842-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NMPA2018-0027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44984227Medicaid