Provider Demographics
NPI:1992192314
Name:SAM, DEVON MICHAEL (CNA, EMT)
Entity Type:Individual
Prefix:MR
First Name:DEVON
Middle Name:MICHAEL
Last Name:SAM
Suffix:
Gender:M
Credentials:CNA, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 HELENA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-8009
Mailing Address - Country:US
Mailing Address - Phone:516-850-0256
Mailing Address - Fax:
Practice Address - Street 1:592 HELENA DR
Practice Address - Street 2:
Practice Address - City:SOUTH HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-8009
Practice Address - Country:US
Practice Address - Phone:516-850-0256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY422848146N00000X
NY343563270614E376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic