Healthcare Provider Details

I. General information

NPI: 1255151478
Provider Name (Legal Business Name): IBRAHIM A FEYISSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 NE 192ND AVE STE 505
VANCOUVER WA
98684-7525
US

IV. Provider business mailing address

180 NE 192ND AVE STE 505
VANCOUVER WA
98684-7525
US

V. Phone/Fax

Practice location:
  • Phone: 503-305-6262
  • Fax:
Mailing address:
  • Phone: 240-839-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number70126165
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: