Provider Demographics
NPI:1356121164
Name:LEGAMO, NARDOS BEKELE
Entity type:Individual
Prefix:
First Name:NARDOS
Middle Name:BEKELE
Last Name:LEGAMO
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 1:2357 108TH LN NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5222
Mailing Address - Country:US
Mailing Address - Phone:612-913-1369
Mailing Address - Fax:
Practice Address - Street 1:2357 108TH LN NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5222
Practice Address - Country:US
Practice Address - Phone:763-780-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNF08231091363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily