Healthcare Provider Details

I. General information

NPI: 1588164396
Provider Name (Legal Business Name): BLEN NIGUSSIE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BLEN NIGUSSIE

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 IRVING ST NW
WASHINGTON DC
20010-2927
US

IV. Provider business mailing address

13324 SHEFFIELD MANOR DR UNIT 4
SILVER SPRING MD
20904-7200
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-4599
  • Fax: 202-877-0448
Mailing address:
  • Phone: 301-768-6518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031432
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: