Provider Demographics
NPI:1720405608
Name:BOTAN, AHMED JAMA
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:JAMA
Last Name:BOTAN
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 1:1615 S 4TH ST APT 3510
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1129
Mailing Address - Country:US
Mailing Address - Phone:612-765-3202
Mailing Address - Fax:
Practice Address - Street 1:419 CEDAR AVE S APT G278
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1032
Practice Address - Country:US
Practice Address - Phone:612-765-3202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle