Provider Demographics
NPI:1316220478
Name:TSABETSAYE, JESSICA LUCILLA WYACO (PA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LUCILLA WYACO
Last Name:TSABETSAYE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:5712 POTENTILLA CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-6240
Mailing Address - Country:US
Mailing Address - Phone:505-720-0606
Mailing Address - Fax:
Practice Address - Street 1:5901 HARPER DR NE
Practice Address - Street 2:PMG URGENT CARE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3587
Practice Address - Country:US
Practice Address - Phone:505-823-8233
Practice Address - Fax:505-823-8059
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2015-02-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2011-0034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19778082Medicaid