Provider Demographics
NPI:1982218806
Name:DESTA, BIRHANU AFSAW
Entity Type:Individual
Prefix:
First Name:BIRHANU
Middle Name:AFSAW
Last Name:DESTA
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 1:2627 E FRANKLIN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-1168
Mailing Address - Country:US
Mailing Address - Phone:161-287-0150
Mailing Address - Fax:
Practice Address - Street 1:2627 E FRANKLIN AVE STE 201
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1168
Practice Address - Country:US
Practice Address - Phone:161-287-0150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty