Provider Demographics
NPI:1871510883
Name:ABDUL-WADUD, BASHIR (PA-C)
Entity type:Individual
Prefix:MR
First Name:BASHIR
Middle Name:
Last Name:ABDUL-WADUD
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:5 PALISADES DR STE 100
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-6433
Practice Address - Country:US
Practice Address - Phone:518-438-4496
Practice Address - Fax:518-438-5803
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1876363AM0700X
PAMA057997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q47997Medicare UPIN
PA457437Medicare PIN