Provider Demographics
NPI:1629851241
Name:MOHAMED, ABDIRAHMAN
Entity Type:Individual
Prefix:
First Name:ABDIRAHMAN
Middle Name:
Last Name:MOHAMED
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 1:909 GOULD AVE NE APT 401
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-4717
Mailing Address - Country:US
Mailing Address - Phone:612-402-4786
Mailing Address - Fax:
Practice Address - Street 1:909 GOULD AVE NE APT 401
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-4717
Practice Address - Country:US
Practice Address - Phone:612-402-4786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNT700218703007172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver