MEDICARE: DOMINIC IRABOR FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	6997	MN

General Provider Information

NPI Number	:	1568003663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC IRABOR FNP-BC

Provider Business Mailing Address
First Line	:	2330 CENTRAL AVE NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-3710
Country	:	US
Telephone Number	:	612-781-1212
Fax Number	:

Provider Business Practice Location Address
First Line	:	2330 CENTRAL AVE NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-3710
Country	:	US
Telephone Number	:	612-781-1212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2019
Last Update Date	:	10/11/2019

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