Provider Demographics
NPI:1487039657
Name:DERESSE, WONDEMNEH ALEMNEH (OWNER)
Entity Type:Individual
Prefix:MR
First Name:WONDEMNEH
Middle Name:ALEMNEH
Last Name:DERESSE
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:WONDEMNEH
Other - Middle Name:ALEMNEH
Other - Last Name:DERESSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:19142 E HAMPDEN DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-5408
Mailing Address - Country:US
Mailing Address - Phone:720-226-5915
Mailing Address - Fax:772-264-5915
Practice Address - Street 1:19142 E, HAMPDEN DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013
Practice Address - Country:US
Practice Address - Phone:720-226-5915
Practice Address - Fax:772-264-5915
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COB-10018343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)