Provider Demographics
NPI:1336628551
Name:GOSHU, TILAHUN MEKONNEN (AGACNP (DNP))
Entity Type:Individual
Prefix:DR
First Name:TILAHUN
Middle Name:MEKONNEN
Last Name:GOSHU
Suffix:
Gender:M
Credentials:AGACNP (DNP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-9734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:417 N 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298
Practice Address - Country:US
Practice Address - Phone:804-828-7748
Practice Address - Fax:804-827-0285
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175864363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC501847806OtherPASSPORT
VAA61230661OtherDRIVERS LICENSE