Healthcare Provider Details

I. General information

NPI: 1720910086
Provider Name (Legal Business Name): BONTU ABERRA DERESSA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 110TH LN NE
BLAINE MN
55449-7702
US

IV. Provider business mailing address

3636 110TH LN NE
BLAINE MN
55449-7702
US

V. Phone/Fax

Practice location:
  • Phone: 763-318-8981
  • Fax:
Mailing address:
  • Phone: 763-318-8981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: