Provider Demographics
NPI:1164279113
Name:ABEBAW, AMANUEL
Entity type:Individual
Prefix:
First Name:AMANUEL
Middle Name:
Last Name:ABEBAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5761 S CROSSBOW PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-3631
Mailing Address - Country:US
Mailing Address - Phone:253-737-8469
Mailing Address - Fax:
Practice Address - Street 1:5761 S CROSSBOW PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-3631
Practice Address - Country:US
Practice Address - Phone:253-737-8469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD07841236172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver