Healthcare Provider Details

I. General information

NPI: 1366353245
Provider Name (Legal Business Name): BINTOU SOUMAORO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MARCY PL APT 6H
BRONX NY
10456-1368
US

IV. Provider business mailing address

200 MARCY PL APT 6H
BRONX NY
10456-1368
US

V. Phone/Fax

Practice location:
  • Phone: 929-452-4299
  • Fax:
Mailing address:
  • Phone: 929-452-4299
  • Fax:

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: