MEDICARE: ADHANOM HABTESLASSIE ASGEDOM

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5023342	NC

General Provider Information

NPI Number	:	1164302584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADHANOM HABTESLASSIE ASGEDOM

Provider Business Mailing Address
First Line	:	2717 NEUSE BLVD
Second Line	:
City	:	NEW BERN
State	:	NC
Zip	:	28562-2840
Country	:	US
Telephone Number	:	252-514-9888
Fax Number	:	252-514-2881

Provider Business Practice Location Address
First Line	:	2717 NEUSE BLVD
Second Line	:
City	:	NEW BERN
State	:	NC
Zip	:	28562-2840
Country	:	US
Telephone Number	:	252-514-9888
Fax Number	:	252-514-2881

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

Provider Enumeration Date	:	09/05/2025
Last Update Date	:	01/12/2026

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