Provider Demographics
NPI:1598547721
Name:IBRAHIMOVIC, MIRZET
Entity Type:Individual
Prefix:
First Name:MIRZET
Middle Name:
Last Name:IBRAHIMOVIC
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 1:806 WASENA AVE SW APT 219
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-5352
Mailing Address - Country:US
Mailing Address - Phone:549-525-1307
Mailing Address - Fax:
Practice Address - Street 1:806 WASENA AVE SW APT 219
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-5352
Practice Address - Country:US
Practice Address - Phone:549-525-1307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant