Healthcare Provider Details

I. General information

NPI: 1942104112
Provider Name (Legal Business Name): MOHAMED IKAR WAYSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7835 3RD ST N STE 108
OAKDALE MN
55128-5445
US

IV. Provider business mailing address

7835 3RD ST N STE 108
OAKDALE MN
55128-5445
US

V. Phone/Fax

Practice location:
  • Phone: 651-666-1267
  • Fax:
Mailing address:
  • Phone: 651-666-1267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: