Provider Demographics
NPI:1992582761
Name:GEBRESILASSIE, DANIEL WELDETENSAE
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:WELDETENSAE
Last Name:GEBRESILASSIE
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 1:3584 PENNSWOOD CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-7878
Mailing Address - Country:US
Mailing Address - Phone:463-999-4054
Mailing Address - Fax:
Practice Address - Street 1:3584 PENNSWOOD CT
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-7878
Practice Address - Country:US
Practice Address - Phone:463-999-4054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INA28206125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily