Provider Demographics
NPI:1962994616
Name:AMERA, ESUBALEW TADESSE
Entity type:Individual
Prefix:
First Name:ESUBALEW
Middle Name:TADESSE
Last Name:AMERA
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 1:5403 ROBINSON LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2920
Mailing Address - Country:US
Mailing Address - Phone:757-272-6331
Mailing Address - Fax:
Practice Address - Street 1:5403 ROBINSON LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2920
Practice Address - Country:US
Practice Address - Phone:757-272-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA901731347C00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle