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General NPI Number Information
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NPI Number | 1497377949
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Entity Type | Individual
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Provider Name | TESFAY MEZGEBE HAILU
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Gender | Male
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Dates
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Enumeration Date | 05/07/2020
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Last Update Date | 04/01/2022
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Provider Practice Location Address
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Address Line | 13350 N 94TH DR STE A101
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City | PEORIA
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State | AZ
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Zip | 85381-4826
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Country | US
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Telephone | 623-974-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 2700 SHANANDALE DR
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City | SILVER SPRING
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State | MD
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Zip | 20904-1632
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Country | US
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Telephone |
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Fax |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 7946
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License Number State | AZ
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