Provider Demographics
NPI:1619456084
Name:WARSAME, ABDIFATAH YUSUF
Entity Type:Individual
Prefix:
First Name:ABDIFATAH
Middle Name:YUSUF
Last Name:WARSAME
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 1:14023 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-6405
Mailing Address - Country:US
Mailing Address - Phone:612-275-7602
Mailing Address - Fax:
Practice Address - Street 1:14023 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378
Practice Address - Country:US
Practice Address - Phone:612-275-7602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNC283025478013172A00000X
MNH448000177616172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver