Healthcare Provider Details

I. General information

NPI: 1912861972
Provider Name (Legal Business Name): ABDIFATAH MAHAT DAHIR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 BLUE GENTIAN RD
SAINT PAUL MN
55121-1564
US

IV. Provider business mailing address

860 BLUE GENTIAN RD
SAINT PAUL MN
55121-1564
US

V. Phone/Fax

Practice location:
  • Phone: 612-261-7454
  • Fax: 612-248-1960
Mailing address:
  • Phone: 612-261-7454
  • Fax: 612-248-1960

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: