Individual
NEBIYU JAMAL FANTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
478 UNIVERSITY AVE W, SAINT PAUL, MN 55103-1935
(202) 779-8511
Mailing address
478 UNIVERSITY AVE W, SAINT PAUL, MN 55103-1935
(202) 779-8511
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
M153136798609
MN
Other
Enumeration date
08/28/2018
Last updated
08/28/2018
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