Provider Demographics
NPI:1003613027
Name:KONSEIMBO OUEDRAOGO, AZETA
Entity type:Individual
Prefix:
First Name:AZETA
Middle Name:
Last Name:KONSEIMBO OUEDRAOGO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 S 132ND ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1899
Mailing Address - Country:US
Mailing Address - Phone:202-288-5352
Mailing Address - Fax:
Practice Address - Street 1:2535 S 152ND AVENUE CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-1969
Practice Address - Country:US
Practice Address - Phone:202-288-5352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor