Healthcare Provider Details

I. General information

NPI: 1013441229
Provider Name (Legal Business Name): TEKLEHAIMANOT ABRAHA DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 BROADWAY SUITE #604
MILLBRAE CA
94030-1905
US

IV. Provider business mailing address

1090 B ST # 162
HAYWARD CA
94541-4108
US

V. Phone/Fax

Practice location:
  • Phone: 415-619-4719
  • Fax:
Mailing address:
  • Phone: 415-619-4719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: