Provider Demographics
NPI:1346021508
Name:TEBEJE, MASRESHAW A
Entity Type:Individual
Prefix:
First Name:MASRESHAW
Middle Name:A
Last Name:TEBEJE
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:PO BOX 2331
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95609-2331
Mailing Address - Country:US
Mailing Address - Phone:916-885-9054
Mailing Address - Fax:
Practice Address - Street 1:3517 MARCONI AVE STE 107C1
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-5328
Practice Address - Country:US
Practice Address - Phone:916-855-9054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9FTF330343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)