Healthcare Provider Details

I. General information

NPI: 1083382055
Provider Name (Legal Business Name): MARYAN MOHAMED AIDEED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

11001 BREN RD E UNIT 709
HOPKINS MN
55343-4446
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-2422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: