Provider Demographics
NPI:1952161929
Name:IBRAHIM, FARDOWSA A
Entity Type:Individual
Prefix:MRS
First Name:FARDOWSA
Middle Name:A
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RAY O VAC DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2469
Mailing Address - Country:US
Mailing Address - Phone:763-250-4716
Mailing Address - Fax:
Practice Address - Street 1:700 RAY O VAC DR STE 2
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2469
Practice Address - Country:US
Practice Address - Phone:608-512-5569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
WI101343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)