Provider Demographics
NPI:1427613470
Name:DIOMANDE, KOSSA
Entity type:Individual
Prefix:
First Name:KOSSA
Middle Name:
Last Name:DIOMANDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3099 KIRKLEVINGTON DR APT 138
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-2480
Mailing Address - Country:US
Mailing Address - Phone:859-494-5888
Mailing Address - Fax:
Practice Address - Street 1:100 FUNKHOUSER BUILDING
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506-0001
Practice Address - Country:US
Practice Address - Phone:859-257-1754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-P363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant