Healthcare Provider Details

I. General information

NPI: 1669055984
Provider Name (Legal Business Name): SHIFERAW TADESSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14500 NE 29TH PL APT 333
BELLEVUE WA
98007-7622
US

IV. Provider business mailing address

14500 NE 29TH PL APT 333
BELLEVUE WA
98007-7622
US

V. Phone/Fax

Practice location:
  • Phone: 206-972-5701
  • Fax:
Mailing address:
  • Phone: 206-972-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: