Healthcare Provider Details

I. General information

NPI: 1083828552
Provider Name (Legal Business Name): TADELE WUNETE ALEMU PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/11/2020
Certification Date: 01/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ARMORY PLACE SUITE 3M
BALTIMORE MD
21201
US

IV. Provider business mailing address

4808 UPLAND DRIVE
ALEXANDRIA VA
22310
US

V. Phone/Fax

Practice location:
  • Phone: 410-225-8615
  • Fax: 410-462-5095
Mailing address:
  • Phone: 703-313-8323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003480
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: