Provider Demographics
NPI:1679941330
Name:MOHAMED, SHUEB
Entity Type:Individual
Prefix:
First Name:SHUEB
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 1:904 AURORA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4739
Mailing Address - Country:US
Mailing Address - Phone:651-815-8183
Mailing Address - Fax:
Practice Address - Street 1:207 25TH ST NW APT C
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2456
Practice Address - Country:US
Practice Address - Phone:218-368-1191
Practice Address - Fax:218-249-0029
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN840633700028171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN840633700028OtherTAXI SERVICES