Provider Demographics
NPI:1346080033
Name:GEBRESELASE, KASSAHUN
Entity type:Individual
Prefix:
First Name:KASSAHUN
Middle Name:
Last Name:GEBRESELASE
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 1:2629 HIGHWAY OO
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7306
Mailing Address - Country:US
Mailing Address - Phone:314-764-0269
Mailing Address - Fax:
Practice Address - Street 1:2629 HIGHWAY OO
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-7306
Practice Address - Country:US
Practice Address - Phone:314-764-0269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOW050163003172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver