Provider Demographics
NPI:1255004180
Name:IBRAHIM, IBRAHIM ALI (ARNP)
Entity Type:Individual
Prefix:MR
First Name:IBRAHIM
Middle Name:ALI
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 DAVIS AVE S APT BB202
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-8239
Mailing Address - Country:US
Mailing Address - Phone:206-697-8181
Mailing Address - Fax:
Practice Address - Street 1:4702 DAVIS AVE S APT BB202
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-8239
Practice Address - Country:US
Practice Address - Phone:206-697-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61151275363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health