Provider Demographics
NPI:1316689185
Name:TASSEW, NAHOM
Entity type:Individual
Prefix:MR
First Name:NAHOM
Middle Name:
Last Name:TASSEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1641 W 67TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-1918
Mailing Address - Country:US
Mailing Address - Phone:213-235-8441
Mailing Address - Fax:
Practice Address - Street 1:1300 N VERMONT AVE STE 902
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6094
Practice Address - Country:US
Practice Address - Phone:323-913-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily