Provider Demographics
NPI:1104645951
Name:BAH, MARIAMA
Entity type:Individual
Prefix:
First Name:MARIAMA
Middle Name:
Last Name:BAH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8103 GILROY DR
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2937
Mailing Address - Country:US
Mailing Address - Phone:703-649-1209
Mailing Address - Fax:
Practice Address - Street 1:6250 US HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5215
Practice Address - Country:US
Practice Address - Phone:325-542-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ152231367500000X
TX1179303367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered