Provider Demographics
NPI:1447979844
Name:BEKUTO, AYANTU G/MEDHIN
Entity type:Individual
Prefix:
First Name:AYANTU
Middle Name:G/MEDHIN
Last Name:BEKUTO
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 1:3309 W 132ND ST
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-1878
Mailing Address - Country:US
Mailing Address - Phone:651-431-1892
Mailing Address - Fax:
Practice Address - Street 1:3309 W 132ND ST
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-1878
Practice Address - Country:US
Practice Address - Phone:651-431-1892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1109755253Z00000X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1109755OtherINDIVIDUAL PROVIDER