Provider Demographics
NPI:1649724576
Name:YAKUBOV, SAMANTHA (PA-C)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:YAKUBOV
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:ALBANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1 HOLLOW LANE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042
Mailing Address - Country:US
Mailing Address - Phone:516-931-0041
Mailing Address - Fax:
Practice Address - Street 1:535 PLANDOME RD FRNT 3
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-1961
Practice Address - Country:US
Practice Address - Phone:516-627-6188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant