Healthcare Provider Details

I. General information

NPI: 1558177394
Provider Name (Legal Business Name): NOUR JAMAL BABA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3934 E STATE ROAD 64
BRADENTON FL
34208-9059
US

IV. Provider business mailing address

3934 E STATE ROAD 64
BRADENTON FL
34208-9059
US

V. Phone/Fax

Practice location:
  • Phone: 941-777-5665
  • Fax: 941-200-4264
Mailing address:
  • Phone: 941-777-5665
  • Fax: 941-200-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: