Healthcare Provider Details

I. General information

NPI: 1144693169
Provider Name (Legal Business Name): MOHAMMED AZEEMUDDIN APRN, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13060 ISLE DR
BAXTER MN
56425-8331
US

IV. Provider business mailing address

13060 ISLE DR
BAXTER MN
56425-8331
US

V. Phone/Fax

Practice location:
  • Phone: 218-828-2880
  • Fax:
Mailing address:
  • Phone: 218-828-2880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013457
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201704860NP-PP
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP4943
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: