Basic Information
| Provider Information | |||||||||
| NPI: | 1851635122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IDRIS | ||||||||
| FirstName: | MUSTAFA | ||||||||
| MiddleName: | MUHAMMAD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18525 NE 58TH CT | ||||||||
| Address2: | APT N2105 | ||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980526708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256383092 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3925 159TH AVE NE | ||||||||
| Address2: | BUILDING 21 | ||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980526309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252160550 | ||||||||
| FaxNumber: | 4252160552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2012 | ||||||||
| LastUpdateDate: | 11/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NX0800X | CH60261762 | WA | Y | Chiropractic Providers | Chiropractor | Orthopedic |
No ID Information.