Provider Demographics
NPI:1255702619
Name:MOHAMED, AYAN (RPA-C)
Entity type:Individual
Prefix:
First Name:AYAN
Middle Name:
Last Name:MOHAMED
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 S. SALINA STREET
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202
Mailing Address - Country:US
Mailing Address - Phone:315-476-7921
Mailing Address - Fax:315-475-1448
Practice Address - Street 1:819 S. SALINA STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202
Practice Address - Country:US
Practice Address - Phone:315-476-7921
Practice Address - Fax:315-475-1448
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019117363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04312089Medicaid
NY04312089Medicaid