Provider Demographics
NPI:1578526794
Name:WONDAFRASH, FIKRE H (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:FIKRE
Middle Name:H
Last Name:WONDAFRASH
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 E 7570 S
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2633
Mailing Address - Country:US
Mailing Address - Phone:801-352-1643
Mailing Address - Fax:
Practice Address - Street 1:5848 S 300 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6121
Practice Address - Country:US
Practice Address - Phone:801-314-4040
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT22Medicare UPIN