Healthcare Provider Details

I. General information

NPI: 1598899213
Provider Name (Legal Business Name): ERMIAS A. GEBRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3269 STOCKTON HILL RD
KINGMAN AZ
86409
US

IV. Provider business mailing address

12032 ARAGON SPRINGS AVE
LAS VEGAS NV
89138-2008
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-2101
  • Fax:
Mailing address:
  • Phone: 23-010-4587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number17672
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number45442
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number45442
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.091301
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLL1567
License Number StateNV
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17672
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: