Provider Demographics
NPI:1619468675
Name:GULTU, ASEFA
Entity type:Individual
Prefix:
First Name:ASEFA
Middle Name:
Last Name:GULTU
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 1:4513 W PIONEER DR APT 620
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-3821
Mailing Address - Country:US
Mailing Address - Phone:469-360-4638
Mailing Address - Fax:
Practice Address - Street 1:4513 W PIONEER DR APT 620
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-3821
Practice Address - Country:US
Practice Address - Phone:469-360-4638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX942366163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse