Healthcare Provider Details

I. General information

NPI: 1053407106
Provider Name (Legal Business Name): MENGESTAB DERI GEBREMESKEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25613 CHASE ST
STEVENSON RANCH CA
91381-1667
US

IV. Provider business mailing address

25613 CHASE ST
STEVENSON RANCH CA
91381-1667
US

V. Phone/Fax

Practice location:
  • Phone: 310-268-3890
  • Fax: 310-268-4611
Mailing address:
  • Phone: 310-268-3890
  • Fax: 310-268-4611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: