Healthcare Provider Details

I. General information

NPI: 1245525344
Provider Name (Legal Business Name): FISEHA M GEBREGIORGIS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 POTOMAC VALLEY RD
ROCKVILLE MD
20850-2757
US

IV. Provider business mailing address

PO BOX 22239
NEW YORK NY
10087-0001
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0004466
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: