MEDICARE: ANDE TEWOLDE TESFAY NURSE PRACTITIONER

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	363LA2200X	Adult Health Nurse Practitioner	AP139951	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NONE	OTHER	TX	NONE

General Provider Information

NPI Number	:	1558835173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDE TEWOLDE TESFAY NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	13419 SARENTO VLG # 314
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77498-2270
Country	:	US
Telephone Number	:	415-568-8230
Fax Number	:

Provider Business Practice Location Address
First Line	:	13419 SARENTO VLG
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77498-2270
Country	:	US
Telephone Number	:	415-568-8230
Fax Number	:

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

Provider Enumeration Date	:	01/16/2019
Last Update Date	:	05/15/2026

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