Provider Demographics
NPI:1093246928
Name:BANGURA, EBRIMA
Entity Type:Individual
Prefix:
First Name:EBRIMA
Middle Name:
Last Name:BANGURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8123 236TH ST SW
Mailing Address - Street 2:APT N302
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-9207
Mailing Address - Country:US
Mailing Address - Phone:206-769-1425
Mailing Address - Fax:
Practice Address - Street 1:8123 236TH ST SW
Practice Address - Street 2:APT N302
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-9207
Practice Address - Country:US
Practice Address - Phone:206-769-1425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00173217390200000X
WAAP60755716363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program