Provider Demographics
NPI:1023580438
Name:FUFA, GUDISSA
Entity Type:Individual
Prefix:
First Name:GUDISSA
Middle Name:
Last Name:FUFA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3027
Mailing Address - Country:US
Mailing Address - Phone:916-474-4000
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-474-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-24
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297282278G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral CareGroup - Single Specialty