Provider Demographics
NPI:1922601004
Name:EJETA, TIGIST T (MIDWIFE)
Entity Type:Individual
Prefix:
First Name:TIGIST
Middle Name:T
Last Name:EJETA
Suffix:
Gender:F
Credentials:MIDWIFE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 E 4TH ST APT 152
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-4528
Mailing Address - Country:US
Mailing Address - Phone:574-220-7034
Mailing Address - Fax:
Practice Address - Street 1:3111 E 4TH ST APT 152
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-4528
Practice Address - Country:US
Practice Address - Phone:574-220-7034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLM240176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife