Healthcare Provider Details

I. General information

NPI: 1386563666
Provider Name (Legal Business Name): BISRAT YSMASHEWA TADESSE AGPCNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 E COSTILLA AVE STE 540
GREENWOOD VILLAGE CO
80112-3648
US

IV. Provider business mailing address

1633 S ANDES CIR
AURORA CO
80017-4573
US

V. Phone/Fax

Practice location:
  • Phone: 720-325-8699
  • Fax:
Mailing address:
  • Phone: 720-325-8699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAG07260071
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: