Healthcare Provider Details

I. General information

NPI: 1285184242
Provider Name (Legal Business Name): MEREB HABTETSION PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 04/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 GEORGIA ST STE B
VALLEJO CA
94590-5905
US

IV. Provider business mailing address

93 VERNON ST APT 2
OAKLAND CA
94610-4241
US

V. Phone/Fax

Practice location:
  • Phone: 707-556-8100
  • Fax:
Mailing address:
  • Phone: 510-260-4059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number53851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: