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General NPI Number Information
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NPI Number | 1053407106
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Entity Type | Individual
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Provider Name | MENGESTAB DERI GEBREMESKEL PA-C
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Gender | Male
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 25613 CHASE ST
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City | STEVENSON RANCH
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State | CA
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Zip | 91381-1667
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Country | US
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Telephone | 310-268-3890
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Fax | 310-268-4611
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Provider Business Mailing Address
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Address Line | 25613 CHASE ST
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City | STEVENSON RANCH
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State | CA
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Zip | 91381-1667
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Country | US
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Telephone | 310-268-3890
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Fax | 310-268-4611
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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