Provider Demographics
NPI:1093073397
Name:GEBRE-AMLAK, KASSATIHUN
Entity Type:Individual
Prefix:
First Name:KASSATIHUN
Middle Name:
Last Name:GEBRE-AMLAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 28TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4835
Mailing Address - Country:US
Mailing Address - Phone:763-559-3779
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-1998
Practice Address - Country:US
Practice Address - Phone:913-588-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-39390207L00000X
MN67534207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology