Provider Demographics
NPI:1164591400
Name:GHEBRESILASIE, EDEN ASEFAW (PA)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:ASEFAW
Last Name:GHEBRESILASIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2642 COLLINS AVE
Mailing Address - Street 2:APT 207
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140
Mailing Address - Country:US
Mailing Address - Phone:305-215-2929
Mailing Address - Fax:
Practice Address - Street 1:18260 NE 19TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-1632
Practice Address - Country:US
Practice Address - Phone:305-956-9062
Practice Address - Fax:305-354-4524
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE3286VMedicare PIN