MEDICARE: HABTOM LEGESE TEWELDEBRAHAN

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	363LF0000X	Family Nurse Practitioner	AP141274	TX

General Provider Information

NPI Number	:	1881261584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HABTOM LEGESE TEWELDEBRAHAN

Provider Business Mailing Address
First Line	:	2727 LBJ FWY STE 326
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75234-7478
Country	:	US
Telephone Number	:	214-935-5791
Fax Number	:	214-935-5717

Provider Business Practice Location Address
First Line	:	2727 LBJ FWY STE 326
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75234-7478
Country	:	US
Telephone Number	:	214-935-5791
Fax Number	:	214-935-5717

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

Provider Enumeration Date	:	06/10/2021
Last Update Date	:	06/10/2021

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Directions to “ HABTOM LEGESE TEWELDEBRAHAN ” Practice Location

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