Provider Demographics
NPI:1083237069
Name:BAH, IDRISSATU (NP)
Entity Type:Individual
Prefix:
First Name:IDRISSATU
Middle Name:
Last Name:BAH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 DUE WEST RD NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1019
Mailing Address - Country:US
Mailing Address - Phone:678-290-5740
Mailing Address - Fax:
Practice Address - Street 1:3116 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1342
Practice Address - Country:US
Practice Address - Phone:404-948-3019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-25
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224670207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine