Provider Demographics
NPI:1750816773
Name:DIALLO, MAMADOU (PA-C)
Entity Type:Individual
Prefix:
First Name:MAMADOU
Middle Name:
Last Name:DIALLO
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 1:1150 WEBSTER AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-5205
Mailing Address - Country:US
Mailing Address - Phone:347-271-7666
Mailing Address - Fax:
Practice Address - Street 1:1150 WEBSTER AVE APT 2D
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-5205
Practice Address - Country:US
Practice Address - Phone:347-271-7666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant