Provider Demographics
NPI:1659902120
Name:YIRDAW, ALEGNTAYE
Entity Type:Individual
Prefix:
First Name:ALEGNTAYE
Middle Name:
Last Name:YIRDAW
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 1:7700 CODY LN APT 3044
Mailing Address - Street 2:
Mailing Address - City:SACHSE
Mailing Address - State:TX
Mailing Address - Zip Code:75048-6687
Mailing Address - Country:US
Mailing Address - Phone:214-205-1319
Mailing Address - Fax:
Practice Address - Street 1:2709 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-6904
Practice Address - Country:US
Practice Address - Phone:214-388-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142463363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology