MEDICARE: FASIKA TEGEGN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1134931066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FASIKA TEGEGN

Provider Business Mailing Address
First Line	:	9819 GLACIAL VALLEY BAY
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55129-7530
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9819 GLACIAL VALLEY BAY
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55129-7530
Country	:	US
Telephone Number	:	612-501-7993
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	01/27/2025

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Directions to “ FASIKA TEGEGN ” Practice Location

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