Provider Demographics
NPI:1447775309
Name:TESFAMARIAM, HAILESELASSIE
Entity Type:Individual
Prefix:MR
First Name:HAILESELASSIE
Middle Name:
Last Name:TESFAMARIAM
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 1:117 BRENTMEADE DR
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-2592
Mailing Address - Country:US
Mailing Address - Phone:757-303-7189
Mailing Address - Fax:757-867-7857
Practice Address - Street 1:117 BRENTMEADE DR
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-2592
Practice Address - Country:US
Practice Address - Phone:757-303-7189
Practice Address - Fax:757-867-7857
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
172A00000X-DRIVEROtherLOGISTICARE