Provider Demographics
NPI:1902942634
Name:MEZGHEBE, WELDEMARIAM (PA)
Entity type:Individual
Prefix:MR
First Name:WELDEMARIAM
Middle Name:
Last Name:MEZGHEBE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12001 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1131
Mailing Address - Country:US
Mailing Address - Phone:301-937-6517
Mailing Address - Fax:
Practice Address - Street 1:7600 CARROLL AVE
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6367
Practice Address - Country:US
Practice Address - Phone:301-891-5447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01669363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical