Provider Demographics
NPI:1912376526
Name:ABRAHAM, MYATU
Entity Type:Individual
Prefix:
First Name:MYATU
Middle Name:
Last Name:ABRAHAM
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 1:277 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 410
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5843
Mailing Address - Country:US
Mailing Address - Phone:651-432-1406
Mailing Address - Fax:
Practice Address - Street 1:277 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 410
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5843
Practice Address - Country:US
Practice Address - Phone:651-432-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant