Provider Demographics
NPI:1760052567
Name:ESHETEA, BAMLAK
Entity Type:Individual
Prefix:
First Name:BAMLAK
Middle Name:
Last Name:ESHETEA
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 1:3310 CIRCLE BROOK DR APT B
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8227
Mailing Address - Country:US
Mailing Address - Phone:571-315-2059
Mailing Address - Fax:
Practice Address - Street 1:3310 CIRCLE BROOK DR APT B
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8227
Practice Address - Country:US
Practice Address - Phone:571-315-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAB65301584172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB65301584OtherID