Provider Demographics
NPI:1194410068
Name:ALI, ABDISAMAD KHALIF
Entity type:Individual
Prefix:
First Name:ABDISAMAD
Middle Name:KHALIF
Last Name:ALI
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 1:5501 NICOLLET AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1946
Mailing Address - Country:US
Mailing Address - Phone:206-708-0478
Mailing Address - Fax:
Practice Address - Street 1:5501 NICOLLET AVE APT 205
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1946
Practice Address - Country:US
Practice Address - Phone:206-708-0478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver