Provider Demographics
NPI:1477201572
Name:MERSHA, SAMRAWIT DEJENE
Entity Type:Individual
Prefix:
First Name:SAMRAWIT
Middle Name:DEJENE
Last Name:MERSHA
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 1:10120 S 20 MILE RD
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-5666
Mailing Address - Country:US
Mailing Address - Phone:720-472-1366
Mailing Address - Fax:
Practice Address - Street 1:3650 E 100TH CT
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-3550
Practice Address - Country:US
Practice Address - Phone:720-472-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0998851363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health