Provider Demographics
NPI:1720592009
Name:MEKONNEN, TINEBETA DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:TINEBETA
Middle Name:DANIEL
Last Name:MEKONNEN
Suffix:
Gender:F
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 1:2762 MATHEWS ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-2245
Mailing Address - Country:US
Mailing Address - Phone:619-807-3236
Mailing Address - Fax:
Practice Address - Street 1:2762 MATHEWS ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-2245
Practice Address - Country:US
Practice Address - Phone:619-807-3236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-25
Last Update Date:2017-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant