Provider Demographics
NPI:1154095461
Name:GEBRESELASSIE, TAWEKE S
Entity Type:Individual
Prefix:
First Name:TAWEKE
Middle Name:S
Last Name:GEBRESELASSIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3834 I PL NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-1359
Mailing Address - Country:US
Mailing Address - Phone:206-484-7663
Mailing Address - Fax:
Practice Address - Street 1:3834 I PL NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-1359
Practice Address - Country:US
Practice Address - Phone:206-484-7663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60166295163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty