Provider Demographics
NPI:1093260622
Name:BEDASSA, BERHANU KEBEDE (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:BERHANU
Middle Name:KEBEDE
Last Name:BEDASSA
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13250 NE SHAVER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1453
Mailing Address - Country:US
Mailing Address - Phone:213-249-6973
Mailing Address - Fax:
Practice Address - Street 1:13250 NE SHAVER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1453
Practice Address - Country:US
Practice Address - Phone:213-249-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61256180163W00000X
CA95004776363LF0000X
OR201606248RN163W00000X
WAAP61370238363LP0808X
OR201707152NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily