Healthcare Provider Details

I. General information

NPI: 1003737743
Provider Name (Legal Business Name): YAQUB ABDIRAHMAN MOHAMED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 PARK AVE STE 2
MINNEAPOLIS MN
55407-1009
US

IV. Provider business mailing address

4259 VERA CRUZ AVE N
CRYSTAL MN
55422-1210
US

V. Phone/Fax

Practice location:
  • Phone: 952-378-1613
  • Fax: 952-513-7771
Mailing address:
  • Phone: 952-378-1613
  • Fax: 952-513-7771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: