Healthcare Provider Details

I. General information

NPI: 1366704553
Provider Name (Legal Business Name): YASSER CHEBLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 01/29/2024
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W
SAINT PAUL MN
55104-3727
US

IV. Provider business mailing address

10961 CLUB WEST PKWY
BLAINE MN
55449-5866
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-2002
  • Fax: 651-326-9635
Mailing address:
  • Phone: 952-914-1727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3472740
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number60702
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: