Healthcare Provider Details

I. General information

NPI: 1760786172
Provider Name (Legal Business Name): HAILELEOUL DESTA ERBELLO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GORMAN AVE APT # 104
LAUREL MD
20707
US

IV. Provider business mailing address

8118 GORMAN AVE APT 104
LAUREL MD
20707-2536
US

V. Phone/Fax

Practice location:
  • Phone: 202-723-4448
  • Fax:
Mailing address:
  • Phone: 202-723-4448
  • Fax: 202-723-4494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA030586
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0003952
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: