Provider Demographics
NPI:1083962971
Name:KEBEDE, HAILU M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:HAILU
Middle Name:M
Last Name:KEBEDE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13808 PROFESSIONAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7948
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:704-602-6563
Practice Address - Street 1:2015 RANDOLPH RD STE 208
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1200
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1817OtherLICENSE