Healthcare Provider Details

I. General information

NPI: 1558034991
Provider Name (Legal Business Name): TEWOLDEBIRHAN BIRU KERESEMO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 CHAMBERS RD
AURORA CO
80011-7112
US

IV. Provider business mailing address

4886 S RIVIERA WAY
AURORA CO
80015-4708
US

V. Phone/Fax

Practice location:
  • Phone: 303-617-2300
  • Fax:
Mailing address:
  • Phone: 720-951-6865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0996238-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0996238-NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRXN.0110013-NP
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number0996238-NP
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: