Provider Demographics
NPI:1326505686
Name:IBRAHIM, ABDIRAZAQ
Entity Type:Individual
Prefix:
First Name:ABDIRAZAQ
Middle Name:
Last Name:IBRAHIM
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 1:1106 COUNTY ROAD D W APT 230
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-7521
Mailing Address - Country:US
Mailing Address - Phone:602-323-4873
Mailing Address - Fax:
Practice Address - Street 1:2931 E LAKE ST # AT
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2614
Practice Address - Country:US
Practice Address - Phone:602-323-4873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health