Provider Demographics
NPI:1194557488
Name:HASSAN, MOHAMUD ALI
Entity type:Individual
Prefix:
First Name:MOHAMUD
Middle Name:ALI
Last Name:HASSAN
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 1:15815 FRANKLIN TRL SE STE 502
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2076
Mailing Address - Country:US
Mailing Address - Phone:612-205-2030
Mailing Address - Fax:
Practice Address - Street 1:15815 FRANKLIN TRL SE STE 502
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-2076
Practice Address - Country:US
Practice Address - Phone:612-205-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH508-055-980-813172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver