Healthcare Provider Details

I. General information

NPI: 1548642903
Provider Name (Legal Business Name): SAMSAM ABDI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 FULLER AVE
SAINT PAUL MN
55104-4829
US

IV. Provider business mailing address

714 FULLER AVE
SAINT PAUL MN
55104-4829
US

V. Phone/Fax

Practice location:
  • Phone: 612-707-8619
  • Fax:
Mailing address:
  • Phone: 612-707-8619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number464522789
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: