Provider Demographics
NPI:1013498872
Name:FANTA, NEBIYU JAMAL
Entity type:Individual
Prefix:
First Name:NEBIYU
Middle Name:JAMAL
Last Name:FANTA
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 1:478 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1935
Mailing Address - Country:US
Mailing Address - Phone:202-779-8511
Mailing Address - Fax:
Practice Address - Street 1:478 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-1935
Practice Address - Country:US
Practice Address - Phone:202-779-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNM153136798609172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver