Provider Demographics
NPI:1073723284
Name:TEFERA, EDEN ANDEBERHAN (PA)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:ANDEBERHAN
Last Name:TEFERA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16028 BEGONIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91708-9249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10301 GARVEY AVE STE 100
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-2180
Practice Address - Country:US
Practice Address - Phone:626-448-0468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17074OtherPA LICENSE NO