Provider Demographics
NPI:1073996179
Name:TESFASION, ELSA E
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:E
Last Name:TESFASION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9003 W CHARLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8106
Mailing Address - Country:US
Mailing Address - Phone:623-444-7140
Mailing Address - Fax:623-444-7140
Practice Address - Street 1:9003 W CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8106
Practice Address - Country:US
Practice Address - Phone:623-444-7140
Practice Address - Fax:623-444-7140
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8568H376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ863798Medicaid