Provider Demographics
NPI:1750049847
Name:TESSEMA, NARDOS
Entity Type:Individual
Prefix:
First Name:NARDOS
Middle Name:
Last Name:TESSEMA
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 1:24326 E KANSAS CIR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80018-6092
Mailing Address - Country:US
Mailing Address - Phone:303-550-0224
Mailing Address - Fax:
Practice Address - Street 1:24326 E KANSAS CIR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80018-6092
Practice Address - Country:US
Practice Address - Phone:303-550-0224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO922303220172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver