MEDICARE: TIRUWORK GUDETA

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	163WG0000X	General Practice Registered Nurse	AP129676	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19348	OTHER	TX	RX.AUTH.NUMBER

General Provider Information

NPI Number	:	1487134730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIRUWORK GUDETA

Provider Business Mailing Address
First Line	:	3519 SWINTON CT
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4809
Country	:	US
Telephone Number	:	240-462-4919
Fax Number	:

Provider Business Practice Location Address
First Line	:	3519 SWINTON CT
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4809
Country	:	US
Telephone Number	:	240-462-4919
Fax Number	:

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

Provider Enumeration Date	:	08/16/2018
Last Update Date	:	08/16/2018

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Directions to “ TIRUWORK GUDETA ” Practice Location

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