Provider Demographics
NPI:1942755830
Name:ABUBAKAR, MARYAM (AGNP-C)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:ABUBAKAR
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 LOUDEN AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2736
Mailing Address - Country:US
Mailing Address - Phone:631-789-7000
Mailing Address - Fax:
Practice Address - Street 1:366 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1170
Practice Address - Country:US
Practice Address - Phone:631-789-7421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307879-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health