Active NPI
Gracie-Ann Samadh Roberts, PHYSICIAN ASSISTANT
- Physician Assistant
- Staten Island, NY
National Provider Identifier
1407045917
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 011794
- Practice address
- 439 Port Richmond Ave
Staten Island, NY 10302-1714 - Phone
- (917) 830-1235
- NPI assigned
- Oct 20, 2007
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 011794 | NY | Primary |
Addresses
Primary practice location
439 Port Richmond Ave
Staten Island, NY 10302-1714
Mailing address
439 Port Richmond Ave
Staten Island, NY 10302-1714
Phone (917) 830-1235
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1192838400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1780531200000",
"number": "1407045917",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "439 PORT RICHMOND AVE",
"city": "STATEN ISLAND",
"state": "NY",
"postal_code": "103021714",
"telephone_number": "917-830-1235"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "439 PORT RICHMOND AVE",
"city": "STATEN ISLAND",
"state": "NY",
"postal_code": "103021714",
"telephone_number": "917-830-1235"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROBERTS",
"first_name": "GRACIE-ANN",
"middle_name": "SAMADH",
"credential": "PHYSICIAN ASSISTANT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-10-20",
"last_updated": "2026-06-04",
"certification_date": "2026-06-04",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "NY",
"license": "011794",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Staten Island, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 4, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.