Provider Demographics
NPI:1619492162
Name:YASSIN, KHADAR MOHAMED
Entity Type:Individual
Prefix:
First Name:KHADAR
Middle Name:MOHAMED
Last Name:YASSIN
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 1:1518 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1750
Mailing Address - Country:US
Mailing Address - Phone:612-281-0730
Mailing Address - Fax:
Practice Address - Street 1:1518 E LAKE STREET
Practice Address - Street 2:202
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407
Practice Address - Country:US
Practice Address - Phone:612-281-0730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN$$$$$$$$$Medicaid