MEDICARE: MR. TESFAY K GSELASSIE CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN 210348	OH
2	367500000X	Certified Registered Nurse Anesthetist	587747	TX

General Provider Information

NPI Number	:	1144219866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TESFAY K GSELASSIE CRNA

Provider Business Mailing Address
First Line	:	PO BOX 650426
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75265-0426
Country	:	US
Telephone Number	:	972-715-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	13601 PRESTON RD
Second Line	:	STE 1000W
City	:	DALLAS
State	:	TX
Zip	:	75240-4911
Country	:	US
Telephone Number	:	972-663-8523
Fax Number	:	972-663-8329

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2005
Last Update Date	:	03/04/2013

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