Provider Demographics
NPI:1780125963
Name:MICHAEL, SAMUEL (RN, FNP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 EASTCHESTER RD
Mailing Address - Street 2:ROOM 213
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2301
Mailing Address - Country:US
Mailing Address - Phone:646-673-4441
Mailing Address - Fax:
Practice Address - Street 1:1825 EASTCHESTER RD
Practice Address - Street 2:ROOM 213
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:646-673-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339919-1363LF0000X
NY654383163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse