Provider Demographics
NPI:1700495694
Name:ISSA, SHARMARKE
Entity Type:Individual
Prefix:
First Name:SHARMARKE
Middle Name:
Last Name:ISSA
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:PO BOX 6088
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-0088
Mailing Address - Country:US
Mailing Address - Phone:612-607-2660
Mailing Address - Fax:612-500-4848
Practice Address - Street 1:4041 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-2900
Practice Address - Country:US
Practice Address - Phone:612-666-0667
Practice Address - Fax:612-500-4848
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician