Provider Demographics
NPI:1235926148
Name:IBRAHIM, MICHAEL JOHN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:IBRAHIM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 S DURBIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2829
Mailing Address - Country:US
Mailing Address - Phone:307-337-4284
Mailing Address - Fax:307-224-3436
Practice Address - Street 1:428 S DURBIN ST STE 104
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2829
Practice Address - Country:US
Practice Address - Phone:307-337-4284
Practice Address - Fax:307-224-3436
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA1343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant