Provider Demographics
NPI:1912629890
Name:HAYATO, DERARTU FESSA
Entity Type:Individual
Prefix:
First Name:DERARTU
Middle Name:FESSA
Last Name:HAYATO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3857 VAN DYKE ST
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4347
Mailing Address - Country:US
Mailing Address - Phone:952-688-7128
Mailing Address - Fax:
Practice Address - Street 1:3857 VAN DYKE ST
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-4347
Practice Address - Country:US
Practice Address - Phone:952-688-7128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1109803364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care