Provider Demographics
NPI:1790521987
Name:EJETA, ABERU E
Entity type:Individual
Prefix:
First Name:ABERU
Middle Name:E
Last Name:EJETA
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 1:6802 CONESTOGA DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-7198
Mailing Address - Country:US
Mailing Address - Phone:972-607-5494
Mailing Address - Fax:
Practice Address - Street 1:6802 CONESTOGA DR
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75089-7198
Practice Address - Country:US
Practice Address - Phone:972-607-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39561535343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)