Healthcare Provider Details

I. General information

NPI: 1548720618
Provider Name (Legal Business Name): YAA B OWUSU-BANAHENE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2019
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 PATTERSON AVE
BALTIMORE MD
21215-2254
US

IV. Provider business mailing address

4120 PATTERSON AVE
BALTIMORE MD
21215-2254
US

V. Phone/Fax

Practice location:
  • Phone: 410-764-2266
  • Fax:
Mailing address:
  • Phone: 410-764-2266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036160225
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH0099435
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: