Provider Demographics
NPI:1336681105
Name:HAILESELASSIE, TIGIST WOLDEGEBRIAL
Entity Type:Individual
Prefix:
First Name:TIGIST
Middle Name:WOLDEGEBRIAL
Last Name:HAILESELASSIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-4525
Mailing Address - Country:US
Mailing Address - Phone:202-723-0393
Mailing Address - Fax:
Practice Address - Street 1:7225 HANOVER PKWY
Practice Address - Street 2:A
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2024
Practice Address - Country:US
Practice Address - Phone:301-345-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006033363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical