Healthcare Provider Details

I. General information

NPI: 1902746530
Provider Name (Legal Business Name): SELAMAWIT WEHABE TSEGA MDCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4958 MEMORIAL DR
STONE MOUNTAIN GA
30083-4148
US

IV. Provider business mailing address

4650 E PONCE DE LEON AVE APT C8
CLARKSTON GA
30021-1822
US

V. Phone/Fax

Practice location:
  • Phone: 404-809-2480
  • Fax:
Mailing address:
  • Phone: 470-749-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: