Provider Demographics
NPI:1245525344
Name:GEBREGIORGIS, FISEHA M (PAC)
Entity type:Individual
Prefix:
First Name:FISEHA
Middle Name:M
Last Name:GEBREGIORGIS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 HANCOCK RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5948
Mailing Address - Country:US
Mailing Address - Phone:928-758-0121
Mailing Address - Fax:928-758-0145
Practice Address - Street 1:1225 HANCOCK RD
Practice Address - Street 2:SUITE C
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5948
Practice Address - Country:US
Practice Address - Phone:928-758-0121
Practice Address - Fax:928-758-0145
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4866363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ$$$$$$$$$OtherTRICARE