Healthcare Provider Details

I. General information

NPI: 1336940014
Provider Name (Legal Business Name): IBRAHEEM AL SHAMMAA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 ELLSWORTH ST
BERKELEY CA
94704-1562
US

IV. Provider business mailing address

2312 ELLSWORTH ST
BERKELEY CA
94704-1562
US

V. Phone/Fax

Practice location:
  • Phone: 916-892-9724
  • Fax:
Mailing address:
  • Phone: 916-892-9724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE195911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: