Provider Demographics
NPI:1194326942
Name:ABDISALAM, SHAKUR
Entity type:Individual
Prefix:
First Name:SHAKUR
Middle Name:
Last Name:ABDISALAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 E OLD SHAKOPEE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2438
Mailing Address - Country:US
Mailing Address - Phone:952-201-4493
Mailing Address - Fax:
Practice Address - Street 1:1440 E OLD SHAKOPEE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-2438
Practice Address - Country:US
Practice Address - Phone:952-201-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN397226251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health