Healthcare Provider Details

I. General information

NPI: 1073854782
Provider Name (Legal Business Name): ABDULFATAH SAID ADAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 CHICAGO AVE APT 32
ST PAUL MN
55104
US

IV. Provider business mailing address

1500 CHICAGO AVE APT 32
MINNEAPOLIS MN
55404-1609
US

V. Phone/Fax

Practice location:
  • Phone: 612-483-0226
  • Fax:
Mailing address:
  • Phone: 612-483-0226
  • Fax: 612-353-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number4000
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: