=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225471956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MLT KIDANE PHYSICIAN ASSISTANT CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2013
-----------------------------------------------------
Last Update Date | 04/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12981 PERRIS BLVD SUITE #101
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92553-4102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-571-0632
-----------------------------------------------------
Fax | 951-571-4149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12981 PERRIS BLVD SUITE #101
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92553-4102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-571-0632
-----------------------------------------------------
Fax | 951-571-4149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. MEAZA Z. KIDANE
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 951-571-0632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA20768
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------