Provider Demographics
NPI:1629229737
Name:MAGASSOUBA, MORIBA (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MORIBA
Middle Name:
Last Name:MAGASSOUBA
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 1:2970 DEDE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:FINKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21048-2349
Mailing Address - Country:US
Mailing Address - Phone:443-487-4053
Mailing Address - Fax:443-906-0610
Practice Address - Street 1:2970 DEDE RD STE 4
Practice Address - Street 2:
Practice Address - City:FINKSBURG
Practice Address - State:MD
Practice Address - Zip Code:21048-2349
Practice Address - Country:US
Practice Address - Phone:443-487-4053
Practice Address - Fax:443-906-0610
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003821363AM0700X
TN1722363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical