Healthcare Provider Details

I. General information

NPI: 1508475807
Provider Name (Legal Business Name): KEFYALEW REGASSA GOBENA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 PARSONS AVE
COLUMBUS OH
43207-1230
US

IV. Provider business mailing address

1493 PARSONS AVE
COLUMBUS OH
43207-1230
US

V. Phone/Fax

Practice location:
  • Phone: 614-882-4343
  • Fax: 614-882-4664
Mailing address:
  • Phone: 614-882-4343
  • Fax: 614-882-4664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.007279RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007279RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: