Provider Demographics
NPI:1972706091
Name:ABOSAMRA, WASSIM (MD)
Entity Type:Individual
Prefix:DR
First Name:WASSIM
Middle Name:
Last Name:ABOSAMRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SOMERSET AVE
Mailing Address - Street 2:
Mailing Address - City:WINDBER
Mailing Address - State:PA
Mailing Address - Zip Code:15963-1329
Mailing Address - Country:US
Mailing Address - Phone:814-467-1640
Mailing Address - Fax:814-467-1624
Practice Address - Street 1:602 EAST 21ST STREET
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18067
Practice Address - Country:US
Practice Address - Phone:610-262-1519
Practice Address - Fax:610-262-7125
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007698380002Medicaid
PA1007698380001Medicaid
PA393820Medicare PIN
PA1007698380002Medicaid
PA393821Medicare PIN
PA136345EWSMedicare PIN