Provider Demographics
NPI:1255676086
Name:TADESSE, ABEBA A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ABEBA
Middle Name:A
Last Name:TADESSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2348
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20875-2348
Mailing Address - Country:US
Mailing Address - Phone:240-629-3912
Mailing Address - Fax:
Practice Address - Street 1:12070 OLD LINE CENTER
Practice Address - Street 2:SUITE 210
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2567
Practice Address - Country:US
Practice Address - Phone:240-629-3952
Practice Address - Fax:240-629-3953
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant