MEDICARE: ENTISAR ABDOSH BEDASSO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1225615693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENTISAR ABDOSH BEDASSO

Provider Business Mailing Address
First Line	:	1821 UNIVERSITY AVE W STE 157
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-2892
Country	:	US
Telephone Number	:	612-259-7715
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 UNIVERSITY AVE W STE 157
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-2892
Country	:	US
Telephone Number	:	612-259-7715
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2021
Last Update Date	:	03/24/2021

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