Provider Demographics
NPI:1063029957
Name:KEBEDE, DESTA (NP)
Entity type:Individual
Prefix:
First Name:DESTA
Middle Name:
Last Name:KEBEDE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST FL 15
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:800-427-1902
Mailing Address - Fax:800-564-5952
Practice Address - Street 1:3417 CONCORD RD STE C
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-9001
Practice Address - Country:US
Practice Address - Phone:717-840-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP022290OtherNP LICENSE