Provider Demographics
NPI:1851956296
Name:ISMAEL, MUSTAFE ABDI
Entity Type:Individual
Prefix:
First Name:MUSTAFE
Middle Name:ABDI
Last Name:ISMAEL
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 1:635 HILLTOP AVE APT C8
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-2700
Mailing Address - Country:US
Mailing Address - Phone:507-213-1575
Mailing Address - Fax:
Practice Address - Street 1:635 HILLTOP AVE APT C8
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-2700
Practice Address - Country:US
Practice Address - Phone:507-213-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR338197355114343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)