Healthcare Provider Details

I. General information

NPI: 1285919985
Provider Name (Legal Business Name): SAMUEL GEBREYONAS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 12/24/2011
Certification Date: GEBREYONAS SAMUEL 3173 WINDFIELD CIR TUCKER GA 30084 1365 CLIFTON RD NE ATLANTA GA 30322
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE OFFICE A-4330
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

3173 WINDFIELD CIR
TUCKER GA
30084-6719
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3914
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care
License Number194592
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: