Provider Demographics
NPI:1912725342
Name:TESFATSION, FRE HAGOS
Entity type:Individual
Prefix:
First Name:FRE
Middle Name:HAGOS
Last Name:TESFATSION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 WESTERVILLE WOODS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-7352
Mailing Address - Country:US
Mailing Address - Phone:614-556-9663
Mailing Address - Fax:
Practice Address - Street 1:3400 WESTERVILLE WOODS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-7352
Practice Address - Country:US
Practice Address - Phone:614-556-9663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6027214602243747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty