Provider Demographics
NPI:1659254274
Name:FARAH, MUSTAFA ((LALD))
Entity type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:
Last Name:FARAH
Suffix:
Gender:M
Credentials:(LALD)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 STEVENS AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3870
Mailing Address - Country:US
Mailing Address - Phone:612-836-9799
Mailing Address - Fax:
Practice Address - Street 1:3234 DUPONT AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-2510
Practice Address - Country:US
Practice Address - Phone:612-836-9799
Practice Address - Fax:612-448-0097
Is Sole Proprietor?:No
Enumeration Date:2025-07-30
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1737364SL0600X, 374U00000X, 376J00000X, 376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
No364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1737OtherMN BOARD OF EXECUTIVES FOR LONG-TERM SERVICES AND SUPPORTS