Provider Demographics
NPI:1649798232
Name:IBRAHIM, ABISOLA (WHNP/AGPCNP)
Entity type:Individual
Prefix:
First Name:ABISOLA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:WHNP/AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-358-4000
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-02
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020023180363LW0102X, 363LA2200X
TX1055965363LG0600X
TN22921363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health