Basic Information
| Provider Information | |||||||||
| NPI: | 1154844686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIALLO-YOUNG | ||||||||
| FirstName: | BOLO | ||||||||
| MiddleName: | OUMAR | ||||||||
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| Credential: | FNP | ||||||||
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| OtherLastName: | DIALLO | ||||||||
| OtherFirstName: | BOLO | ||||||||
| OtherMiddleName: | O | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 549 BEAN ST # 1 | ||||||||
| Address2: | |||||||||
| City: | ANOKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553032040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6129866063 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554151623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128733000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 07/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5272 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.