=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144693169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMED AZEEMUDDIN APRN, CNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2015
-----------------------------------------------------
Last Update Date | 02/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13060 ISLE DR
-----------------------------------------------------
City | BAXTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56425-8331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-828-2880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13060 ISLE DR
-----------------------------------------------------
City | BAXTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56425-8331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-828-2880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209013457
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 201704860NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CNP4943
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------