Healthcare Provider Details

I. General information

NPI: 1962388173
Provider Name (Legal Business Name): DR. HOMAN MIRALIABKBARI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 08/25/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 MAIN STREET NORTH
PLENTYWOOD MT
59254
US

IV. Provider business mailing address

12111 51 AVE NW SUITE NUMBER 210
EDMONTON ALBERTA
T6H 6A3
CA

V. Phone/Fax

Practice location:
  • Phone: 306-502-9315
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number117943
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: