Healthcare Provider Details

I. General information

NPI: 1336623222
Provider Name (Legal Business Name): BENIAM TEFERA ABEBE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 05/08/2022
Certification Date: 05/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 GLENRIDGE DR STE 200
ATLANTA GA
30328-5579
US

IV. Provider business mailing address

1561 JANMAR RD
SNELLVILLE GA
30078-5639
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-5206
  • Fax:
Mailing address:
  • Phone: 678-344-8900
  • Fax: 678-666-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8985
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: