Provider Demographics
NPI:1750035135
Name:ISMAIL, ABDIRISAK
Entity type:Individual
Prefix:
First Name:ABDIRISAK
Middle Name:
Last Name:ISMAIL
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 1:1363 10TH ST NW APT 202
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6746
Mailing Address - Country:US
Mailing Address - Phone:763-290-4178
Mailing Address - Fax:
Practice Address - Street 1:1363 10TH ST NW APT 202
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6746
Practice Address - Country:US
Practice Address - Phone:763-290-4178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor