Provider Demographics
NPI:1114675840
Name:GIZATU, TEWODROS DESIE (PMHNP)
Entity Type:Individual
Prefix:DR
First Name:TEWODROS
Middle Name:DESIE
Last Name:GIZATU
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 1:321 116TH ST S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-5405
Mailing Address - Country:US
Mailing Address - Phone:253-537-3022
Mailing Address - Fax:
Practice Address - Street 1:321 116TH ST S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-5405
Practice Address - Country:US
Practice Address - Phone:253-537-3022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60732624163W00000X
WAAP61266932363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse