Provider Demographics
NPI:1033667266
Name:ASFAW, WOSSEN ADINEW
Entity Type:Individual
Prefix:
First Name:WOSSEN
Middle Name:ADINEW
Last Name:ASFAW
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 1:3575 KROGER BLVD SUITE 116
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-9004
Mailing Address - Country:US
Mailing Address - Phone:770-923-4433
Mailing Address - Fax:
Practice Address - Street 1:3575 KOGER BLVD STE 116
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-7559
Practice Address - Country:US
Practice Address - Phone:770-923-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1133058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant