Provider Demographics
NPI:1780227744
Name:TADESSE, SINTAYEHU A
Entity Type:Individual
Prefix:
First Name:SINTAYEHU
Middle Name:A
Last Name:TADESSE
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 1:1602 S PARKER RD STE 107
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-2920
Mailing Address - Country:US
Mailing Address - Phone:720-273-7889
Mailing Address - Fax:
Practice Address - Street 1:1602 S PARKER RD STE 107
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-2920
Practice Address - Country:US
Practice Address - Phone:720-273-7889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO04P550364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO216066021Medicaid