Provider Demographics
NPI:1396266987
Name:GUGESSA, AMSALE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:AMSALE
Middle Name:
Last Name:GUGESSA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:AMSAL
Other - Middle Name:
Other - Last Name:GUGSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:1666 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-3561
Mailing Address - Country:US
Mailing Address - Phone:925-278-3269
Mailing Address - Fax:
Practice Address - Street 1:9925 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94603-2558
Practice Address - Country:US
Practice Address - Phone:510-777-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily