Provider Demographics
NPI:1558034991
Name:KERESEMO, TEWOLDEBIRHAN BIRU (NP)
Entity Type:Individual
Prefix:
First Name:TEWOLDEBIRHAN
Middle Name:BIRU
Last Name:KERESEMO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4886 S RIVIERA WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4708
Mailing Address - Country:US
Mailing Address - Phone:720-951-6865
Mailing Address - Fax:
Practice Address - Street 1:113 SEABOARD LN STE 200B
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-8282
Practice Address - Country:US
Practice Address - Phone:615-905-6944
Practice Address - Fax:800-266-5158
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0996238-NP363LG0600X, 364SA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health