Provider Demographics
NPI:1699448431
Name:FANTU, YIDNEKACHEW
Entity type:Individual
Prefix:
First Name:YIDNEKACHEW
Middle Name:
Last Name:FANTU
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 1:2707 CRYSTAL FALLS PKWY
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-3587
Mailing Address - Country:US
Mailing Address - Phone:512-636-8945
Mailing Address - Fax:
Practice Address - Street 1:2707 CRYSTAL FALLS PKWY
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-3587
Practice Address - Country:US
Practice Address - Phone:512-636-8945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver