Healthcare Provider Details

I. General information

NPI: 1639682925
Provider Name (Legal Business Name): DEREJE BEYENE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 15TH STREET NORTH
SAINT CLOUD MN
56303
US

IV. Provider business mailing address

1406 15TH STREET NORTH
SAINT CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2278C0205X
TaxonomyCritical Care Certified Respiratory Therapist
License Number4049
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: