Provider Demographics
NPI:1568091114
Name:DIKIBO, AUSTIN TARIBO (PA-C)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:TARIBO
Last Name:DIKIBO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8116 GOOD LUCK RD STE 305
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3508
Mailing Address - Country:US
Mailing Address - Phone:301-552-1200
Mailing Address - Fax:
Practice Address - Street 1:8116 GOOD LUCK RD STE 305
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3508
Practice Address - Country:US
Practice Address - Phone:301-552-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant