Healthcare Provider Details

I. General information

NPI: 1003767559
Provider Name (Legal Business Name): SIRAJ ISSAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2026
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 23RD ST S STE D
FARGO ND
58103-3759
US

IV. Provider business mailing address

1323 23RD ST S STE D
FARGO ND
58103-3759
US

V. Phone/Fax

Practice location:
  • Phone: 701-781-0208
  • Fax:
Mailing address:
  • Phone: 701-781-0208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: