Provider Demographics
NPI:1912548256
Name:DIARRASSOUBA, AMIDOU (PA)
Entity Type:Individual
Prefix:MR
First Name:AMIDOU
Middle Name:
Last Name:DIARRASSOUBA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 WALTON AVE APT 4BS
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-7807
Mailing Address - Country:US
Mailing Address - Phone:646-730-2841
Mailing Address - Fax:
Practice Address - Street 1:1265 WALTON AVE APT 4BS
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-7807
Practice Address - Country:US
Practice Address - Phone:646-730-2841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program