Healthcare Provider Details

I. General information

NPI: 1255224192
Provider Name (Legal Business Name): EKRAM A IDRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 DAYTON AVE STE 106A
SAINT PAUL MN
55104-6206
US

IV. Provider business mailing address

1410 NICOLLET AVE APT 3221410
MINNEAPOLIS MN
55403-2600
US

V. Phone/Fax

Practice location:
  • Phone: 206-519-8842
  • Fax:
Mailing address:
  • Phone: 206-519-8842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: