Provider Demographics
NPI:1043884117
Name:TEWOLDE, NYAT FREWEYNI (PA-C)
Entity Type:Individual
Prefix:
First Name:NYAT
Middle Name:FREWEYNI
Last Name:TEWOLDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NIYAT
Other - Middle Name:OKBU
Other - Last Name:TEWELDEBRHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 100744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3196 S MARYLAND PKWY STE 425
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2318
Practice Address - Country:US
Practice Address - Phone:725-205-0725
Practice Address - Fax:725-204-5251
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2421363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA59112OtherPHYSICIAN ASSISTANT
NVPA2421OtherPHYSICIAN ASSISTANT