Provider Demographics
NPI:1497467401
Name:BAH, BOUBACAR
Entity Type:Individual
Prefix:
First Name:BOUBACAR
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 1:1631 FOREST RD APT 204
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1414
Mailing Address - Country:US
Mailing Address - Phone:630-362-8334
Mailing Address - Fax:
Practice Address - Street 1:1631 FOREST RD APT 204
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1414
Practice Address - Country:US
Practice Address - Phone:630-362-8334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026536363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health