Provider Demographics
NPI:1336525666
Name:IBRAHIM, IDRISS (CNP)
Entity Type:Individual
Prefix:
First Name:IDRISS
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 BIRCH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1550
Mailing Address - Country:US
Mailing Address - Phone:507-530-6028
Mailing Address - Fax:
Practice Address - Street 1:309 E COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2379
Practice Address - Country:US
Practice Address - Phone:507-530-6028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6251207Q00000X
MN228248-6251E00000X
MN077579-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1336525666OtherNPI