Healthcare Provider Details

I. General information

NPI: 1467957936
Provider Name (Legal Business Name): YUSSR M IBRAHIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 LAWRENCE DR STE 103
DE PERE WI
54115-9108
US

IV. Provider business mailing address

1716 LAWRENCE DR STE 103
DE PERE WI
54115-9108
US

V. Phone/Fax

Practice location:
  • Phone: 920-632-6800
  • Fax: 920-632-6806
Mailing address:
  • Phone: 920-632-6800
  • Fax: 920-632-6806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD27051
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD27051
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: