Healthcare Provider Details

I. General information

NPI: 1720332844
Provider Name (Legal Business Name): LEOLSEGED LEGESSE-MULUSHEWA PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

1355 PEABODY ST NW APT 209
WASHINGTON DC
20011-1874
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-8130
  • Fax:
Mailing address:
  • Phone: 202-468-6142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA030848
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0004755
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: