Provider Demographics
NPI:1912397613
Name:TESSEMA, KIDANE
Entity Type:Individual
Prefix:
First Name:KIDANE
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 1:1718 N JUPITER RD APT 2136
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-8625
Mailing Address - Country:US
Mailing Address - Phone:214-404-5238
Mailing Address - Fax:
Practice Address - Street 1:7929 BROOKRIVER DR STE 180
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4920
Practice Address - Country:US
Practice Address - Phone:214-525-0681
Practice Address - Fax:972-349-6595
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126837363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty