Provider Demographics
NPI:1932528213
Name:ALI IDRIS, AMROU M
Entity Type:Individual
Prefix:
First Name:AMROU
Middle Name:M
Last Name:ALI IDRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:AMROU
Other - Middle Name:MOHAMMED OMER
Other - Last Name:ALI IDRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-474-3260
Mailing Address - Fax:509-474-3245
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-3260
Practice Address - Fax:509-474-3245
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60763663207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program