Provider Demographics
NPI:1760786172
Name:ERBELLO, HAILELEOUL DESTA (PA)
Entity Type:Individual
Prefix:
First Name:HAILELEOUL
Middle Name:DESTA
Last Name:ERBELLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8118 GORMAN AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-2536
Mailing Address - Country:US
Mailing Address - Phone:202-723-4448
Mailing Address - Fax:202-723-4494
Practice Address - Street 1:8118 GORMAN AVE
Practice Address - Street 2:APT # 104
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707
Practice Address - Country:US
Practice Address - Phone:202-723-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030586363AM0700X
MDC0003952363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical