Healthcare Provider Details

I. General information

NPI: 1700245628
Provider Name (Legal Business Name): ASEFA K GEBRE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 E AIRPORT DR
CARTHAGE MO
64836-3402
US

IV. Provider business mailing address

327 E AIRPORT DR
CARTHAGE MO
64836-3402
US

V. Phone/Fax

Practice location:
  • Phone: 417-237-0604
  • Fax: 417-237-0613
Mailing address:
  • Phone: 417-237-0604
  • Fax: 417-237-0613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2016004134
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: