Provider Demographics
NPI:1013531904
Name:ANDEMARYAM, NATHNAEL
Entity Type:Individual
Prefix:
First Name:NATHNAEL
Middle Name:
Last Name:ANDEMARYAM
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 1:7945 E COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-2032
Mailing Address - Country:US
Mailing Address - Phone:323-891-0614
Mailing Address - Fax:
Practice Address - Street 1:7945 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-2032
Practice Address - Country:US
Practice Address - Phone:323-891-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO170770702172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver