Provider Demographics
NPI:1992489603
Name:KIDANE, YOHANNES ANDOM
Entity type:Individual
Prefix:
First Name:YOHANNES
Middle Name:ANDOM
Last Name:KIDANE
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 1:9695 E ARKANSAS PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-5698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 RED CREEK SPRINGS RD LOT 54
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-9723
Practice Address - Country:US
Practice Address - Phone:720-492-7581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)