Provider Demographics
NPI:1699511253
Name:WAGESSO, FEYISSA JAFAR
Entity type:Individual
Prefix:
First Name:FEYISSA
Middle Name:JAFAR
Last Name:WAGESSO
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 1:2468 BRENNER AVE E
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1573
Mailing Address - Country:US
Mailing Address - Phone:763-910-7300
Mailing Address - Fax:218-979-7692
Practice Address - Street 1:2468 BRENNER AVE E
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1573
Practice Address - Country:US
Practice Address - Phone:763-910-7300
Practice Address - Fax:218-979-7692
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility