Provider Demographics
NPI:1053925644
Name:MANSHAD, IBRAHIM
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:MANSHAD
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 1:321 E TITUS ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-5907
Mailing Address - Country:US
Mailing Address - Phone:512-299-6704
Mailing Address - Fax:
Practice Address - Street 1:321 E TITUS ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-5907
Practice Address - Country:US
Practice Address - Phone:512-299-6704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA604078893-001-0001171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter