Provider Demographics
NPI:1659969293
Name:ASFAHA, SELAM
Entity Type:Individual
Prefix:
First Name:SELAM
Middle Name:
Last Name:ASFAHA
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 1:19159 ENCORE CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8081
Mailing Address - Country:US
Mailing Address - Phone:952-220-9333
Mailing Address - Fax:
Practice Address - Street 1:19159 ENCORE CT
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-8081
Practice Address - Country:US
Practice Address - Phone:952-220-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle