Healthcare Provider Details

I. General information

NPI: 1689395295
Provider Name (Legal Business Name): HASSAN ABDISALAM MOHAMED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/03/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S. CRISMON RD
MESA AZ
85209
US

IV. Provider business mailing address

1301 S CRISMON RD
MESA AZ
85209-3767
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-3000
  • Fax:
Mailing address:
  • Phone: 480-358-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11818
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: