Provider Demographics
NPI:1871330969
Name:HASSAN, FARDOWSA
Entity type:Individual
Prefix:
First Name:FARDOWSA
Middle Name:
Last Name:HASSAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-0800
Mailing Address - Country:US
Mailing Address - Phone:907-302-9893
Mailing Address - Fax:
Practice Address - Street 1:570 1ST ST SE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-0800
Practice Address - Country:US
Practice Address - Phone:907-302-9893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health