Basic Information
Provider Information | |||||||||
NPI: | 1134407430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ABLA | ||||||||
FirstName: | EYAS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D, | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 CENTRACARE CIR # 1300 | ||||||||
Address2: | CENTRACARE CLINIC WOMEN & CHILDREN, ALLERGY/IMMUNOLOGY | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563035000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3206543650 | ||||||||
FaxNumber: | 3206543647 | ||||||||
Practice Location | |||||||||
Address1: | 1900 CENTRACARE CIR # 1300 | ||||||||
Address2: | CENTRACARE CLINIC WOMEN & CHILDREN, ALLERGY/IMMUNOLOGY | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563035000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3206543650 | ||||||||
FaxNumber: | 3206543647 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2011 | ||||||||
LastUpdateDate: | 09/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 108882 | MN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207K00000X | 108882 | MN | Y |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   |
No ID Information.