Provider Demographics
NPI:1750031068
Name:HAILEMARIAM, MOGES LEMMA (FNP/DNP)
Entity Type:Individual
Prefix:DR
First Name:MOGES
Middle Name:LEMMA
Last Name:HAILEMARIAM
Suffix:
Gender:M
Credentials:FNP/DNP
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NA
Mailing Address - Street 1:1156 BONNEVILLE CT
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-5820
Mailing Address - Country:US
Mailing Address - Phone:510-417-2494
Mailing Address - Fax:
Practice Address - Street 1:3160 GARRITY WAY
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-1983
Practice Address - Country:US
Practice Address - Phone:510-758-7462
Practice Address - Fax:866-509-2661
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC6360511283OtherNATIONAL REGISTRY OF CERTIFIED MEDICAL EXAMINER