Provider Demographics
NPI:1740970995
Name:TEWOLDE, SENAIT M
Entity type:Individual
Prefix:
First Name:SENAIT
Middle Name:M
Last Name:TEWOLDE
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 1:1535 N CHINA LAKE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-2667
Mailing Address - Country:US
Mailing Address - Phone:760-446-1691
Mailing Address - Fax:
Practice Address - Street 1:1535 N CHINA LAKE BLVD STE A
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2667
Practice Address - Country:US
Practice Address - Phone:760-446-1691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant