Healthcare Provider Details

I. General information

NPI: 1619400157
Provider Name (Legal Business Name): MAMADOU MOUCTAR BAH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HYGEIA DR
NEWARK DE
19713-2049
US

IV. Provider business mailing address

749 MIDDLETOWN WARWICK RD
MIDDLETOWN DE
19709-9095
US

V. Phone/Fax

Practice location:
  • Phone: 302-273-1701
  • Fax: 302-273-4497
Mailing address:
  • Phone: 302-273-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009253
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number020752-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0012025
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: