Provider Demographics
NPI:1508456583
Name:FARAH, DEQA ABDULQADIR (RDN)
Entity Type:Individual
Prefix:
First Name:DEQA
Middle Name:ABDULQADIR
Last Name:FARAH
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 TOWN CENTRE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2318
Mailing Address - Country:US
Mailing Address - Phone:612-814-7878
Mailing Address - Fax:
Practice Address - Street 1:1130 TOWN CENTRE DR APT 3
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2318
Practice Address - Country:US
Practice Address - Phone:612-814-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1018484133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered