Healthcare Provider Details

I. General information

NPI: 1780416297
Provider Name (Legal Business Name): MUKTAR HASSAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 10TH AVE S APT 213
FARGO ND
58103-2077
US

IV. Provider business mailing address

4325 10TH AVE S APT 213
FARGO ND
58103-2077
US

V. Phone/Fax

Practice location:
  • Phone: 207-409-7331
  • Fax:
Mailing address:
  • Phone: 207-409-7331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: