Provider Demographics
NPI:1316147168
Name:TANTU, AFEWORK YACOB
Entity type:Individual
Prefix:MR
First Name:AFEWORK
Middle Name:YACOB
Last Name:TANTU
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 1:5021 SEMINARY RD
Mailing Address - Street 2:APT#1109
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1945
Mailing Address - Country:US
Mailing Address - Phone:571-239-0621
Mailing Address - Fax:
Practice Address - Street 1:5021 SEMINARY RD
Practice Address - Street 2:APT#1109
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1945
Practice Address - Country:US
Practice Address - Phone:571-239-0621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1316343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0000Medicaid