Healthcare Provider Details

I. General information

NPI: 1912548256
Provider Name (Legal Business Name): AMIDOU DIARRASSOUBA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6271 FLEETWOOD CT APT 2
FORT RILEY KS
66442-3333
US

IV. Provider business mailing address

1265 WALTON AVE APT 4BS
BRONX NY
10452-7807
US

V. Phone/Fax

Practice location:
  • Phone: 646-730-2841
  • Fax:
Mailing address:
  • Phone: 646-730-2841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: