Healthcare Provider Details

I. General information

NPI: 1740776574
Provider Name (Legal Business Name): AYAT KHIDIR ABDELGADIR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 07/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 SERVICE RD
EAST LANSING MI
48824-7013
US

IV. Provider business mailing address

313 N CEDAR ST APT 212
LANSING MI
48912-1289
US

V. Phone/Fax

Practice location:
  • Phone: 517-432-2404
  • Fax:
Mailing address:
  • Phone: 571-645-0320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301115099
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: