Provider Demographics
NPI:1265067466
Name:SAM, MANJU BIJU
Entity type:Individual
Prefix:MRS
First Name:MANJU
Middle Name:BIJU
Last Name:SAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BERWYN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1923
Mailing Address - Country:US
Mailing Address - Phone:631-525-1801
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-1923
Practice Address - Country:US
Practice Address - Phone:631-632-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-08
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309300-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health