Provider Demographics
NPI:1487211710
Name:EBSA, TSEGAYE MAMO
Entity Type:Individual
Prefix:
First Name:TSEGAYE
Middle Name:MAMO
Last Name:EBSA
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 1:2184 S JOPLIN WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-1028
Mailing Address - Country:US
Mailing Address - Phone:720-341-4631
Mailing Address - Fax:
Practice Address - Street 1:2184 S JOPLIN WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-1028
Practice Address - Country:US
Practice Address - Phone:720-341-4631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COXOD558343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)