Provider Demographics
NPI:1083223473
Name:EYASU, MICHEALE
Entity Type:Individual
Prefix:
First Name:MICHEALE
Middle Name:
Last Name:EYASU
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 1:2780 S ENSENADA CT
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-4746
Mailing Address - Country:US
Mailing Address - Phone:720-629-4939
Mailing Address - Fax:
Practice Address - Street 1:2780 S ENSENADA CT
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-4746
Practice Address - Country:US
Practice Address - Phone:720-629-4939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84-3926057Medicaid