Basic Information
| Provider Information | |||||||||
| NPI: | 1003262668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIR | ||||||||
| FirstName: | IZZA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 1ST DR NW | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559122941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074337351 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 1ST DR NW | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559122941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074337351 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OT017043 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 72609 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.