Provider Demographics
NPI:1962029785
Name:BERHANE, ABIEL ANDEMARIAM
Entity Type:Individual
Prefix:
First Name:ABIEL
Middle Name:ANDEMARIAM
Last Name:BERHANE
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 1:3690 WATERFORD PL
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-1443
Mailing Address - Country:US
Mailing Address - Phone:404-551-6120
Mailing Address - Fax:
Practice Address - Street 1:1133 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5085
Practice Address - Country:US
Practice Address - Phone:678-604-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-27
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10046367H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program