Provider Demographics
NPI:1497512214
Name:NEGASH, KIDIST
Entity Type:Individual
Prefix:
First Name:KIDIST
Middle Name:
Last Name:NEGASH
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 1:1425 S DUQUESNE CT
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80018-6143
Mailing Address - Country:US
Mailing Address - Phone:720-400-3539
Mailing Address - Fax:
Practice Address - Street 1:2175 ACADEMY CIR STE 201-3
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1695
Practice Address - Country:US
Practice Address - Phone:720-400-3539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver