Healthcare Provider Details

I. General information

NPI: 1336681105
Provider Name (Legal Business Name): TIGIST WOLDEGEBRIAL HAILESELASSIE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3357B CORRIDOR MARKETPLACE
LAUREL MD
20724-2381
US

IV. Provider business mailing address

4903 GEORGIA AVE NW
WASHINGTON DC
20011-4525
US

V. Phone/Fax

Practice location:
  • Phone: 301-497-1820
  • Fax:
Mailing address:
  • Phone: 202-723-0393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0006033
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: