Provider Demographics
NPI:1255819819
Name:ALI, AYAN OSMAN
Entity type:Individual
Prefix:
First Name:AYAN
Middle Name:OSMAN
Last Name:ALI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 ENERGY PARK DR STE 12
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5249
Mailing Address - Country:US
Mailing Address - Phone:612-814-7815
Mailing Address - Fax:
Practice Address - Street 1:1410 ENERGY PARK DR STE 12
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5249
Practice Address - Country:US
Practice Address - Phone:612-814-7815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-04
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1972962926Medicaid