Provider Demographics
NPI:1356598031
Name:GHEBRETATIOS, GHENET (NP)
Entity type:Individual
Prefix:
First Name:GHENET
Middle Name:
Last Name:GHEBRETATIOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 ESSEN LN STE 500
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3738
Mailing Address - Country:US
Mailing Address - Phone:225-767-1311
Mailing Address - Fax:225-767-1335
Practice Address - Street 1:4950 ESSEN LN STE 500
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3738
Practice Address - Country:US
Practice Address - Phone:225-767-1311
Practice Address - Fax:225-766-0218
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA091641-03998363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1120812Medicaid
LAP58360Medicare UPIN
LA4C225C696Medicare PIN