Provider Demographics
NPI:1063093482
Name:KIDANE, TEMESGEN ALEM (PTA)
Entity type:Individual
Prefix:MR
First Name:TEMESGEN
Middle Name:ALEM
Last Name:KIDANE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3529
Mailing Address - Country:US
Mailing Address - Phone:419-221-6715
Mailing Address - Fax:866-675-2004
Practice Address - Street 1:4125 HUNTERS PARK LN STE 116
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-7615
Practice Address - Country:US
Practice Address - Phone:407-855-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30969225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant