Healthcare Provider Details

I. General information

NPI: 1982516704
Provider Name (Legal Business Name): SHAMSA ISSACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 1ST AVE N STE L
FARGO ND
58102-4264
US

IV. Provider business mailing address

1709 1ST AVE N STE L
FARGO ND
58102-4264
US

V. Phone/Fax

Practice location:
  • Phone: 701-373-6975
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: