Healthcare Provider Details

I. General information

NPI: 1194786467
Provider Name (Legal Business Name): IBKHAN ANSINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

IV. Provider business mailing address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

V. Phone/Fax

Practice location:
  • Phone: 320-225-3335
  • Fax: 320-225-3345
Mailing address:
  • Phone: 320-225-3335
  • Fax: 320-225-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41439
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number41439
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: