Provider Demographics
NPI:1003504473
Name:FELEKE, KEDUSE W
Entity Type:Individual
Prefix:MR
First Name:KEDUSE
Middle Name:W
Last Name:FELEKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ASALEFEW
Other - Middle Name:F
Other - Last Name:WOLDEGIORGISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5716 N BLACK CANYON HWY APT 48
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-2110
Mailing Address - Country:US
Mailing Address - Phone:623-299-5688
Mailing Address - Fax:
Practice Address - Street 1:5716 N BLACK CANYON HWY APT 48
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-2110
Practice Address - Country:US
Practice Address - Phone:623-299-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ172A00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver