Provider Demographics
NPI:1417528225
Name:BIZUNEH, HAILEGIORGIS T
Entity Type:Individual
Prefix:
First Name:HAILEGIORGIS
Middle Name:T
Last Name:BIZUNEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11551 NUCKOLS RD STE P
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5565
Mailing Address - Country:US
Mailing Address - Phone:804-593-5935
Mailing Address - Fax:804-593-5977
Practice Address - Street 1:11551 NUCKOLS RD STE P
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5565
Practice Address - Country:US
Practice Address - Phone:804-593-5935
Practice Address - Fax:804-593-5977
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-03
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181571363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health