Provider Demographics
NPI:1215349998
Name:KIDANE, EYOB G (PA-C)
Entity type:Individual
Prefix:
First Name:EYOB
Middle Name:G
Last Name:KIDANE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5257
Mailing Address - Country:US
Mailing Address - Phone:509-416-8849
Mailing Address - Fax:509-542-3059
Practice Address - Street 1:7425 WRIGLEY DR
Practice Address - Street 2:STE 100
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5292
Practice Address - Country:US
Practice Address - Phone:509-416-8888
Practice Address - Fax:509-545-6842
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA51493363A00000X
WA60564696363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant