Provider Demographics
NPI:1164999660
Name:DEBELE, TADESSE KEBEDE (MD, MS)
Entity Type:Individual
Prefix:
First Name:TADESSE
Middle Name:KEBEDE
Last Name:DEBELE
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 N STOCKTON HILL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4622
Mailing Address - Country:US
Mailing Address - Phone:928-681-8701
Mailing Address - Fax:
Practice Address - Street 1:2202 N STOCKTON HILL RD STE 101
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4622
Practice Address - Country:US
Practice Address - Phone:702-877-5199
Practice Address - Fax:702-431-0265
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR7887207Q00000X
NVPA2058363A00000X
AZR78887390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1164999660Medicaid