Provider Demographics
NPI:1851936009
Name:ISSA, MUNTAHA Y
Entity Type:Individual
Prefix:
First Name:MUNTAHA
Middle Name:Y
Last Name:ISSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9220 BASS LAKE RD STE 395
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3110
Mailing Address - Country:US
Mailing Address - Phone:763-400-6350
Mailing Address - Fax:
Practice Address - Street 1:9220 BASS LAKE RD STE 395
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3110
Practice Address - Country:US
Practice Address - Phone:763-400-6350
Practice Address - Fax:763-201-3797
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN84-3654226Medicaid