Provider Demographics
NPI:1508636796
Name:KERSEMA, TEMESGEN ASFAW
Entity Type:Individual
Prefix:
First Name:TEMESGEN
Middle Name:ASFAW
Last Name:KERSEMA
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 1:619 N JORDAN ST APT 103
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-5427
Mailing Address - Country:US
Mailing Address - Phone:571-435-5477
Mailing Address - Fax:
Practice Address - Street 1:619 N JORDAN ST APT 103
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-5427
Practice Address - Country:US
Practice Address - Phone:571-435-5477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA69692887343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)