Healthcare Provider Details

I. General information

NPI: 1730041138
Provider Name (Legal Business Name): ABEBE MIHIRET MEKONNEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

12511 POSTGROVE DR APT H
SAINT LOUIS MO
63146-4572
US

IV. Provider business mailing address

12511 POSTGROVE DR APT H
SAINT LOUIS MO
63146-4572
US

V. Phone/Fax

Practice location:
  • Phone: 646-353-4638
  • Fax:
Mailing address:
  • Phone: 646-353-4638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number20220018566
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: