Provider Demographics
NPI:1861917668
Name:ENGIDA, YIGREM
Entity type:Individual
Prefix:
First Name:YIGREM
Middle Name:
Last Name:ENGIDA
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 1:119 RACINE ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-2729
Mailing Address - Country:US
Mailing Address - Phone:901-239-4105
Mailing Address - Fax:
Practice Address - Street 1:119 RACINE ST STE 103
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-2729
Practice Address - Country:US
Practice Address - Phone:901-239-4105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN089714532172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver