MEDICARE: TIGIST E DESTA FNP

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	363LF0000X	Family Nurse Practitioner	APN.0999728-NP	CO

General Provider Information

NPI Number	:	1558198887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIGIST E DESTA FNP

Provider Business Mailing Address
First Line	:	27870 E LAKEVIEW DR
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80016-2864
Country	:	US
Telephone Number	:	720-240-3810
Fax Number	:

Provider Business Practice Location Address
First Line	:	10180 E COLFAX AVE
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80010-5038
Country	:	US
Telephone Number	:	303-900-8639
Fax Number	:

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

Provider Enumeration Date	:	09/19/2024
Last Update Date	:	09/19/2024

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