Healthcare Provider Details

I. General information

NPI: 1891243358
Provider Name (Legal Business Name): MOHAMED FARAH FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2218 E LAKE ST
MINNEAPOLIS MN
55407-5095
US

IV. Provider business mailing address

2218 E LAKE ST
MINNEAPOLIS MN
55407-5095
US

V. Phone/Fax

Practice location:
  • Phone: 612-800-2839
  • Fax:
Mailing address:
  • Phone: 612-800-2839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP161085
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN52206
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12473
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: