Healthcare Provider Details

I. General information

NPI: 1285693739
Provider Name (Legal Business Name): HANY NASSIF YACOUB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 03/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9055 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5841
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 763-780-9155
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36766
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: