Provider Demographics
NPI:1447032719
Name:SANNI, MUSTAPHA A
Entity type:Individual
Prefix:
First Name:MUSTAPHA
Middle Name:A
Last Name:SANNI
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 1:604 GROVE RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4209
Mailing Address - Country:US
Mailing Address - Phone:478-387-8041
Mailing Address - Fax:
Practice Address - Street 1:607 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4208
Practice Address - Country:US
Practice Address - Phone:478-387-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program