Provider Demographics
NPI:1114302809
Name:BAH, ISSA
Entity Type:Individual
Prefix:MR
First Name:ISSA
Middle Name:
Last Name:BAH
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 1:800 VICTORY BLVD APT 5W
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3721
Mailing Address - Country:US
Mailing Address - Phone:347-898-0528
Mailing Address - Fax:
Practice Address - Street 1:800 VICTORY BLVD APT 5W
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3721
Practice Address - Country:US
Practice Address - Phone:347-898-0528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291999-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse