MEDICARE: MASRESHA HAILU WODAJO

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	343900000X	Non-emergency Medical Transport (VAN)		AZ

General Provider Information

NPI Number	:	1467143073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MASRESHA HAILU WODAJO

Provider Business Mailing Address
First Line	:	5728 N BLACK CANYON HWY APT 13
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85017-2108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5728 N BLACK CANYON HWY APT 13
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85017-2108
Country	:	US
Telephone Number	:	602-327-3041
Fax Number	:

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

Provider Enumeration Date	:	05/16/2023
Last Update Date	:	05/16/2023

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Directions to “ MASRESHA HAILU WODAJO ” Practice Location

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