Provider Demographics
NPI:1508475807
Name:GOBENA, KEFYALEW REGASSA (PA-C)
Entity Type:Individual
Prefix:
First Name:KEFYALEW
Middle Name:REGASSA
Last Name:GOBENA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-8116
Mailing Address - Fax:614-293-5315
Practice Address - Street 1:915 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3153
Practice Address - Country:US
Practice Address - Phone:614-293-8116
Practice Address - Fax:614-293-5315
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007279RX363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0467560Medicaid