Provider Demographics
NPI:1609619030
Name:SAMUELS, MIRIAM RISA (CM)
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:RISA
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:CM
Other - Prefix:MRS
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:SAMUELS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CM
Mailing Address - Street 1:126 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1923
Mailing Address - Country:US
Mailing Address - Phone:516-816-6562
Mailing Address - Fax:
Practice Address - Street 1:126 MONROE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1923
Practice Address - Country:US
Practice Address - Phone:516-816-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF002310-01367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife