Provider Demographics
NPI:1336499698
Name:GEBREMARIAM, FASIKA GETAHUN (CERTIFICATE)
Entity Type:Individual
Prefix:
First Name:FASIKA
Middle Name:GETAHUN
Last Name:GEBREMARIAM
Suffix:
Gender:M
Credentials:CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4248 OCTOBER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4876
Mailing Address - Country:US
Mailing Address - Phone:615-815-7892
Mailing Address - Fax:
Practice Address - Street 1:4248 OCTOBER WOODS DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-4876
Practice Address - Country:US
Practice Address - Phone:615-815-7892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN478337247100000X, 2471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging