Provider Demographics
NPI:1356039937
Name:HASSAN, MOHAMED KHALIF
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:KHALIF
Last Name:HASSAN
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 1:649 OLD HIGHWAY 8 NW APT 146
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-2871
Mailing Address - Country:US
Mailing Address - Phone:612-735-6668
Mailing Address - Fax:
Practice Address - Street 1:1821 UNIVERSITY AVE W STE 107-23
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-0049
Practice Address - Country:US
Practice Address - Phone:612-735-6668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1111642374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty