Healthcare Provider Details

I. General information

NPI: 1154296002
Provider Name (Legal Business Name): AYANLE URDOOH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 MINNEHAHA AVE W APT 106
SAINT PAUL MN
55104-1518
US

IV. Provider business mailing address

907 MINNEHAHA AVE W APT 106
SAINT PAUL MN
55104-1518
US

V. Phone/Fax

Practice location:
  • Phone: 651-202-7403
  • Fax:
Mailing address:
  • Phone: 651-202-7403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberQ387106405118
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: