Healthcare Provider Details

I. General information

NPI: 1801783311
Provider Name (Legal Business Name): EFRAM GEBRENEGUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2939 E ROOSEVELT ST APT 57
PHOENIX AZ
85008-5048
US

IV. Provider business mailing address

2939 E ROOSEVELT ST APT 57
PHOENIX AZ
85008-5048
US

V. Phone/Fax

Practice location:
  • Phone: 602-900-3949
  • Fax:
Mailing address:
  • Phone: 602-900-3949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: