Provider Demographics
NPI:1265802961
Name:ISACK, ALI
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:ISACK
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 1:1041 JAMES AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-3936
Mailing Address - Country:US
Mailing Address - Phone:701-630-9374
Mailing Address - Fax:
Practice Address - Street 1:1041 JAMES AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3936
Practice Address - Country:US
Practice Address - Phone:701-630-9374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNB992051697320172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver