Healthcare Provider Details

I. General information

NPI: 1043135403
Provider Name (Legal Business Name): MAIDAH ABDULAHI OMAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11972 PORTLAND AVE
BURNSVILLE MN
55337-1516
US

IV. Provider business mailing address

7619 WHITNEY DR
APPLE VALLEY MN
55124-5403
US

V. Phone/Fax

Practice location:
  • Phone: 952-698-0750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: