Provider Demographics
NPI:1083307805
Name:ABEBAW, ANDAULEM WUBETU
Entity Type:Individual
Prefix:
First Name:ANDAULEM
Middle Name:WUBETU
Last Name:ABEBAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANDUALEM
Other - Middle Name:ABEBAW
Other - Last Name:WUBETU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8500 E MISSISSIPPI AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-2206
Mailing Address - Country:US
Mailing Address - Phone:720-277-8979
Mailing Address - Fax:
Practice Address - Street 1:8500 E MISSISSIPPI AVE APT 1
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-2206
Practice Address - Country:US
Practice Address - Phone:720-277-8979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver